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COPYRIGHT DEPOSIT. 






Case of pellagra, showing typic " gauntlet." (Patient of Dr. G. A. Zeller.) 



PELLAGRA 

AN AMERICAN PROBLEM 



BY 

GEORGE M. NILES, M.D. 

M 

GASTRO-ENTEROLOGIST TO THE GEORGIA BAPTIST HOSPITAL, WESLEY 
MEMORIAL HOSPITAL, AND ATLANTA HOSPITAL; CONSULTING GASTRO- 
ENTEROLOGIST TO THE ATLANTA ANTITUBERCULOSIS ASSOCIATION AND TO 
THE MOORE MEMORIAL CLINIC, ATLANTA, GEORGIA 



SECOND EDITION 
ILLUSTRATED 



PHILADELPHIA AND LONDON 

W. B. SAUNDERS COMPANY 
1916 






<* 






\* 



Copyright, 191 2, by W. B. Saunders Company. 
Reprinted October, 191 2. Revised, re- 
printed, and recopyrighted 
January, 1916 



Copyright, 1916, by W. B. Saunders Company 



PRINTED !N AMERICA 



PRESS OF 

W. B. SAUNDERS COMPANY 

PHILADELPHIA 




JAN 2b J9I6 

JI.A420553 



TO 

CHARLES E. BOYNTON, A. B., M. D., 

THIS VOLUME IS INSCRIBED 

AS A TRIBUTE TO HIS HIGH PROFESSIONAL 

ATTAINMENTS AND IN REMEMBRANCE 

OF HIS MANY ACTS OF KINDNESS, 

BY THE AUTHOR 



PREFACE TO THE SECOND EDITION 



The success of the first edition of this book seemed to 
indicate that it filled a need of the profession. In this 
second edition many changes and additions have been 
made, bringing the consideration of Pellagra as a national 
problem up to our present state of knowledge. 

The chapter on Etiology contains the result of the inves- 
tigations of Dr. Joseph Goldberger, Special U. S. Agent for 
the study of this disease, and the Thompson-McFadden 
Pellagra Commission, whose careful and scientific labors 
have received deserved commendation. The efforts of 
other students have also been recognized. 

The chapter on Treatment contains a number of late 
therapeutic suggestions, including the employment of em- 
etin for the frequently ameba-infected mouth and intes- 
tines, the scarlet ointment for obstinate dermatitis, and 
others, which I have found helpful. 

I am indebted to numerous friends for criticisms and con- 
structive advice; and especially to the members of the 
Thompson-McFadden Commission, who have both officially 
and personally extended valuable aid, is offered grateful 
acknowledgment. 

While the causation of Pellagra is not yet entirely proved, 
the conviction is expressed that we are much nearer the 
goal of etiologic certainty, pathologic assurance, and conse- 
quent therapeutic confidence. 

George M. Niles. 

920 Candler Building, 

Atlanta, Ga. 
January, igi6. 



PREFACE 



In presenting this work I feel that a literature on the 
subject of pellagra should be advanced by American ob- 
servers. 

We should not be deterred because of its recent visita- 
tion, nor should we be content to leave its investigation 
to our friends in Europe, though they have been wrestling 
with this problem for near two centuries; and we may find 
it difficult to rival them in erudition as well as the profund- 
ity with which they have considered some of the unsolved 
pathologic and etiologic questions. A condition confronts 
us, and we must needs be up and doing in order to meet it. 

I have no apology to offer for expressing my candid 
opinions and firm convictions. Should subsequent experi- 
ence and knowledge convince me that I have fostered error, 
I shall be the first to announce it and make the necessary 
amends. No advancement has ever been made except by 
following a new idea to an established fact, and in the light 
which is now guiding me I can see no incorrect premise nor 
any false conclusions; yet I do not expect the approbation 
of all whose opinions I court and whose words I respect. 

To go forward and not backward in the management of 
this threatened scourge will require much clinical observa- 
tion, much laboratory labor, special technic in the examina- 
tion and treatment of the various phases of pellagra, a 



8 PREFACE 

practical knowledge of physiology and physiologic chem- 
istry, the medical uses of special drugs, baths, waters, and 
electricity, and, with it all, time and patience. 

It will be most interesting a few years hence to look back 
in a retrospective manner on the efforts of to-day, on the 
possibly erroneous viewpoints with which we have consid- 
ered pellagra, and our somewhat halting footsteps in its 
therapeutics. We are glad in this connection, however, to 
lay to our souls the flattering unction that our efforts are at 
least sincere and justified by present results. 

To many kind friends I convey my appreciation for help- 
ful suggestions and other courtesies; but particularly do I 
wish to thank Dr. J. W. Babcock, of Columbia, and Dr. C. 
H. Lavinder, of the Public Health and Marine-Hospital Ser- 
vice, for both their encouragement and consideration. 

To the medical profession I offer this book for what it is, 
not claiming that it speaks the "last word," but that it rep- 
resents the labors of a student who is endeavoring with a 
spirit of courage and optimism to contribute a worthy por- 
tion to the sum total of our information concerning pellagra, 
this American problem. 

George M. Niles. 

920 Candler Building, 
Atlanta, Ga. 



CONTENTS 



CHAPTER I 

PAGE 

General Considerations, Historic and Otherwise n 



CHAPTER II 

Pellagra in the United States 25 

CHAPTER III 
A Discussion of the Etiology of Pellagra 34 

CHAPTER IV 

Symptomatology ^nd Clinical Course of Pellagra 77 

CHAPTER V 

Clinical Reports and Description of Cases of Pellagra from 

Different Sources 132 

CHAPTER VI 

Pathology and Morbdd Anatomy of Pellagra 154 

CHAPTER VII 

Diagnosis, Course and Progress, and Prognosis of Pellagra.. 168 

CHAPTER VIII 

The Treatment of Pellagra— A Discussion of Different 

Methods 184 

9 



IO CONTENTS 

CHAPTER IX 

PAGE 

The Prophylaxis of Pellagra 213 

CHAPTER X 

Descriptions of Some Recent Experiments on Animals, and 

Deductions Therefrom 231 



Bibliographic Index 249 

Index 253 



PELLAGRA 



CHAPTER I 



GENERAL CONSIDERATIONS, HISTORIC AND 
OTHERWISE 

Pellagra, as an American problem, is now receiving 
marked attention in many sections of this country. Up 
to less than eight years ago it appeared upon the sociologic 
horizon as a cloud no larger than a man's hand, but it 
has continued to grow and expand, until at present it 
looms up before the sober observer with portentous 
solemnity. 

Pellagra may be defined as an endemic malady, char- 
acterized by an erythema (generally symmetric) upon the 
exposed surfaces of the body, by gastro-intestinal dis- 
turbances, and by nervous and psychic phenomena. 

This definition is necessarily incomplete, for to de- 
scribe this protean disease in a few words would require 
the graphic imagination of a Carlyle, or the word-paint- 
ing of a Macaulay. 

The synonyms for pellagra are numerous, among which 
are Alpine Scurvy, Asturian Leprosy, Asturian Rose, Dis- 
ease of the Landes, Maidismus, Psychoneurosis Maidica, 

11 



12 PELLAGRA 

Mai de la Rosa, Mai del Sole, Mai de Misere, Mai del 
Padrone, and many others. 

To Frapolli we owe the present name of the disease 
(pelle, skin, and agra, rough), and the same writer de- 
clared that the disease was an ancient one, and none 
other than the sickness pellarella, which was noted in 
1578 by the authorities of the Hospital Major, of 
Milan. 

As to the pronunciation, the varieties are almost legion. 
It would seem fair to permit a man the privilege of pro- 
nouncing his own name; or to the resident of a state or 
country the like privilege of pronouncing the name of 
his abode. For instance, we grant to the residents of 
Iowa the right to say Ioway, or to those living in Arkansas 
the rather bizarre-sounding Arkansaw. By this same 
token it seems proper to permit the Italians, who gave us 
the name, to also teach us the pronunciation. After con- 
sulting with not a few, but with many educated Italians, 
those in a position to speak with authority, the writer is 
convinced that the most widely accepted pronunciation 
gives the a in pellagra the same sound as in the word 
father, with the accent on the second syllable. 

Some, of course, will take issue with this, as would be 
the case with any other word not possessing the sanction 
of ancient and world-wide custom in its pronunciation; 
but the sound of a in this word, as given above, is prob- 
ably used more than any other. 

To trace back the history of this disease, among the 
rather scattered archives of the middle ages, is both in- 
teresting and difficult. Dr. Howard D. King, of New Or- 
leans, recently contributed a most valuable historic study 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 13 

of pellagra, and to him, as well as to Dr. A. Marie, we are 
indebted for much of this data. 

To weave a history of pellagra without encountering 
the visage of maize seems almost impossible. Through 
the tangled skein, as it is interwoven with the destinies of 
several nations and peoples, we see the rise and decline 
of pellagra almost coincident with the consumption of 
Indian corn; and, try as we may, we cannot disassociate 
the two. 

In 1600 Baruino, in a medical treatise, called attention 
to a peculiar malady prevailing among certain tribes of 
the American Indians. From his incomplete description, 
it apparently resembled the pellagra of to-day. Even 
then he ascribed it to the use of corn, which the Indians 
used constantly as a part of their diet. 

Francisco Scipione, an Italian poet, archeologist, and 
litterateur, also described a similar disease but a few months 
after Baruino, his description being much more com- 
plete. About this time there was also noted a peculiar 
disease among horses, in which those animals seemed 
both paretic and tabetic, showing a malnutrition with 
loss of hair. This was supposed to have been produced 
by feeding them spoiled corn. 

In Spain corn was introduced as an article of food in 
the period between 1680 and 1700. Strange to say, the 
first authentic accounts of pellagra appeared just about 
this time. According to Babes and Sion, as claimed by 
Dr. Babcock, it is probable that pellagra appeared in 
Europe long before its scientific description, but was 
classed as either gastro-intestinal, or nervous, or mental, 
or leprous, or scorbutic diseases. It is, therefore, some- 



14 PELLAGRA 

what difficult to determine whether or not pellagra ap- 
peared in Europe before the advent of Indian corn as a 
food. 

The first really scientific account is ascribed to Gaspar 
Casal, who, in 1735, observed it in the vicinity of Oviedo. 
Several years later he wrote of it fully, describing it as 
seen in the Asturias, and giving it the name "Mai de 
Rosa." For a long time the disease was found only in 
this region, and in somewhat narrow limits. Even to 
this day Oviedo seems a focus. 

In Italy it appeared about twenty-five years later than 
in Spain. Frapolli, to whom, as previously said, we are 
indebted for the word pellagra, believed he had found 
a picture of pellagra in the description of la pellarella in 
1578. This was more probably a case of syphilis. About 
the time Frapolli named it, Adoardi, of Venetia, called 
it "scorbutus alpinus." 

By 1776, also a notable year in American annals, the 
disease had spread to such an extent that the Venetian 
authorities, at the request of the Sanitary Commission 
of Venice, issued an edict prohibiting the sale or exchange 
in the public markets of corn having a bad odor or taste, 
or which was discolored. Even at that time, exacerba- 
tions and remissions of pellagra during different seasons 
of the year were noted, for D'Oleggio, in 1784, suggested 
the term "vernal insolation," meaning the "sunburn of 
spring." Also in that year a special hospital for those 
afflicted in this manner, and for special study of the dis- 
ease, was established in Legano by royal warrant, and 
called the Joseph II Pellagra Asylum. The elder Stram- 
bio, a man admirably fitted by both education and tern- 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 15 

perament for such a position, was appointed chief physi- 
cian. 

From this period, up to 1839, but little was done to 
check the ravages of pellagra, when Ballardino declared 
that it was produced by eating damaged maize, claiming 
that he had demonstrated it beyond a perad venture. 
His views, as happens to any one making radical state- 
ments, met with ridicule, and, while the discussion waxed 
warm, the flames of the disease spread with amazing rapid- 
ity. From 1839 to 1856, a space of seventeen years, there 
was an increase of from 14 to 28 per thousand, or from 
20,282 to 38,777. This alarming increase brought the 
Lombard government to action, and it was high time. 
A commission from the Institute Lombardo was appointed 
to investigate, and to report ways and means to combat 
this state of affairs. Commissions, like petit juries, are 
often remarkable bodies, and this was no exception. They 
reported that while, in their opinion, Ballardino's theory 
as to spoiled or damaged maize being a causative factor 
was in the main correct, they did not believe that a diet 
free from maize would either exert a favorable influence 
or prevent the disease. 

It would appear that there were then, as in this day, 
factional differences among the bodies of thought, 
where, unfortunately, prejudice was permitted to blind 
sober judgment, and personal animus to warp scientific 
conclusions. 

'This commission, therefore, attributed the improve- 
ment in the afflicted peasantry, not to elimination of 
corn as a food, but more hygienic methods of living. 

'Twas ever thus. 



16 PELLAGRA 

To give an idea of the amazing spread of pellagra during 
those years, it might be mentioned that, in the province 
of Vicenzo, the number of known pellagrins between 1853 
and 1855 was 1380; in i860, 2974; and 1879, 3400. These 
figures covered only one province. 

In 1879 it was estimated that the number of peasants 
suffering with pellagra had reached the appalling number 
of 97,855, being distributed as follows: Lombardy, 40,838; 
Venetia, 29,386; Emilia, 18,728; Tuscany, 4382; Marches 
and Umbria, 2155; Piedmont, 1692; Liguria, 148; Rome, 76. 

In Lombardy, where the disease always seemed to flour- 
ish most, the worst infected centers were Buscia, Pavia, 
Piancenza, and Ferrara. Next to Lombardy, it was most 
severe in Venetia and Emilia. In these three provinces 
the number of pellagrins in 1880 formed about 30 per 
1000 of the whole agricultural population. This was also 
reflected in the military reports from those provinces, for 
from 18 to 20 per cent, of the conscripts were reported 
unfit for duty on account of illness of this character. 
Furthermore, in Italy, there were, in 1874, 945 pellagrous 
lunatics. In 1877 there were 1348. 

The years 187 1 to 1884 showed the "high- water mark" 
of this disease, 104,067 being officially reported. There 
was but little fluctuation in the figures until 1899, when 
there appeared a noticeable decline among the afflicted 
peasantry. 

In a government report "Analli di Agricoltura, No. 18," 
which, to an extent, corresponds to the bulletins issued 
by our Public Health and Marine Hospital Service, is 
published the melancholy pellagra statistics for the St. 
Clement's Hospital of Venice for a period of six years 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 17 

preceding, and it shows, with frightful distinctness, the 
extent of the "el delirio della miseria," as the Italians 
call it: 

Total number insane. Pellagrous insane. 

1874 558 178 

1875 595 iS3 

1876 666 175 

1877 802 215 

1878 859 294 

1879 924 337 

Total 4404 I35 2 

In 1884 conservative estimates placed the number of 
pellagrins in Italian hospitals and insane asylums at 
10,000, and the civic burden was so onerous that a bill, 
aimed at the prevention, was introduced in the Chamber of 
Deputies at Rome through the efforts of the Zannardelli 
cabinet in 1902. 

In 1903 there were thought to be about 60,000 cases in 
Italy proper, though some of the statistics were unreliable. 
The last census of 1905 shows but 55,000 pellagrins in that 
country, and well-posted observers consider that this number 
has remained almost stationary up to the present date. 

There are several reasons mentioned by Dr. L. W. 
Sambon which militate against correct reports; the pa- 
tient does not always admit having pellagra; there is no 
compulsion requiring the authorities to be notified; and, 
not the least important, is the fact that local pride and a 
desire to show a decrease in a given locality cause the 
knowledge of some cases to be suppressed. Sambon, 
therefore, thinks that at present a fair estimate of pella- 
grins in Italy would be 100,000, though he admits that 
the mortality is not near so great as formerly. This 
briefly but fairly covers the situation in Italy. 
2 



I 8 PELLAGRA 

In France, too, pellagra has wielded an important 
place in history. First reported in the vicinity of Arca- 
chon in Gascony in 1818, it steadily spread along the 
coast of the Gironde and the Landes. Marchand, in 1826, 
called attention to its prevalence in the southern prov- 
inces of France. Dr. Petit, an observing French physi- 
cian, of that locality, noted it about 1828, stating that 
it was more common in the Landes than in the Gironde 
district, and that at one time there were about 200 cases 
in a population of 6000. 

According to Dr. C. H. Lavinder, it was first observed 
in France by the elder Hameau in the vicinity of Teste 
in 18 1 8, whence came the French appellation "maladie de 
la Teste." 

From these districts, the malady spread along the 
left bank of the river Garonne and toward the Pyrenees 
Mountains. Fortunately for the people in the vicinity of 
Dax, the disease never assumed serious proportions there. 

From 1829 to 1880, pellagra was one of the live sub- 
jects in the sociologic thought and literature of France. 
But, as remarked by Regis, there suddenly came a silence, 
and for the last thirty years but few cases have been 
reported. This sudden change is hard to explain. Some 
think that it has simply disappeared, "like the figment 
of a vision, leaving not a rack behind"; others think that 
there has been established a gradual immunity, or that 
the people have become so habituated to it that they 
have lost both interest and fear, viewing it with that 
fatalistic indifference of the Oriental. 

At any rate, pellagra is no longer noticeable in France 
to any extent. Happy country! 

In Spain, according to Triller, in spite of intelligent 




-Egyptian case of pellagra, taken after death. (Courtesy of Dr. F. N. 

Sand with.) 




.. Egyptian case of pellagra, showing symmetric " gauntlet " and 
" anklet "; also showing the pellagrous " breast-plate " observed in those 
whose breasts are habitually exposed to the sun. (Case of Dr. Sandwith.) 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 19 

prophylaxis, this disease at present affects fully 20 per 
cent, of the inhabitants of certain provinces. It should 
not be forgotten that here, in the Asturias, pellagra was 
first described in 1735. 

Casal spoke of the conditions there as follows: "Corn 
is the principal food of the laborer there; soups are made 
of it, to which they usually add milk; they likewise eat 
eggs, fish, and cheese; very rarely they buy fresh meat 
and occasionally salt meat." 

"Here, as elsewhere, they begin by misconceiving the 
real origin of the affection," for different writers attempted 
to prove that it came from leprosy. Their hypotheses, 
of course, were not proved. 

In Roumania the first recorded case was in 18 10, and it 
seems comparatively easy to trace the progress of the dis- 
ease along with the importation of wet and damaged corn 
by the inferior vessels of the coastwise trade. 

From the period between 1833 to 1846 pellagra attracted 
much attention, and was called by the people "Buba 
Tranjilar." 

Between 1854 and 1859 the government began to take 
notice, finding 4500 recognized cases in Moldavia and 
Wallachia. In 1885 this number had grown to 16,260, and 
in 1886 to 19,797. 

In 1898 the peasant population of Roumania was esti- 
mated at 5,300,000, and the statistics pointed to 21,000 
pellagrins among this number. 

In 1906 Triller thought there were at least 30,000 there, 
and in 1907 other observers estimated the number at 
40,000. 

Corfu, one of the Ionian islands, famed in song and 
story, has also suffered the burden of this affliction. It 



20 PELLAGRA 

became epidemic there in 1856, and at this day exists in 
30 out of the 117 communes. The percentage of pella- 
grins in the whole population is probably 3.2 per 1000 
inhabitants. Typhaldos, of Corfu, has given the disease 
much study, and from him we have gotten some valuable 
information from many viewpoints. 

Austria has not been exempt, for in the Tyrol, espe- 
cially in Bukowina, having a population of 38,000, 2.9 per 
cent, are pellagrous. In this region of Austria there are 
seventeen institutions, where the peasantry can get proper 
food, and receive instructions as to cooking, hygiene, and 
other helpful knowledge. 

This country has deeply considered the situation in its 
legislative assemblies, has enacted wise laws, restraining 
and educational, and seems to have the disease well in hand. 

In Great Britain, only two cases were reported up to 
19 13, one by Drs. Brown and Carruthers, of Rock Ferry, 
and the other by Drs. R. Dods Brown and Cranston Low, 
assistant physicians in the Royal Edinburg Asylum. Since 
that date, however, Dr. Sambon has discovered many pre- 
viously undiagnosed cases in England, 53 being observed 
in one hospital. 

In Africa, as in other warm countries, this malady has 
gained a strong foothold. It was first recognized in 1847, 
by Pruner, who had observed it previously in Italy. 

Pruner's statements did not meet with a favorable 
reception, for Hirsh and others "laughed him to scorn." 
Nothing further was said or done, until 1892, when, at a 
medical congress held at Cairo, Dr. F. N. Sandwith, senior 
physician and lecturer on medicine, Kasr-el-Ainy Hospital, 
Cairo, read a splendid paper on pellagra and its prevention. 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 21 

He stated that, through the courtesy of Dr. J. Warnock, 
superintendent of the lunatic asylum of that region, he 
saw 40 or 50 pellagrous lunatics. Since 1893, Dr. Sand- 
with has seen more than 1100 cases, and asserts that it is 
quite prevalent in Lower Egypt, though not so much in 
Upper Egypt. He thinks that the proportion of those 
who lose their minds is not so large in Egypt as in Italy, 
though unable to explain why. 

Dr. C. H. Lavinder, who has studied in Egypt also, 
rather differs from some of Dr. Sandwith's conclusions, 
mainly as to its slight prevalence in Upper Egypt. 

Leaving for a time the consideration of this disease 
among the congested populations of the "Old World," 
we come nearer home, and still do we find the hideous face 
of this specter confronting us at every stage of our in- 
vestigations. Suffice it to say, that hardly a country in 
Southern Europe has escaped, for Algeria, Tunis, Bul- 
garia, Servia, Portugal, Dalmatia, Croatia, Bosnia, Tur- 
key, and even as far north as Poland, where freedom 
shrieked when Kosciusco fell, do we find it. 

It will be most interesting to note the effect on the future 
prevalence of pellagra that may result from the European 
war now raging. These enlightening facts must, of neces- 
sity, be left to the historian of a later day. 

In Jamaica, in 1888, Dr. Henry Strachan, senior medical 
officer, reported 510 cases of "malarial multiple neuritis," 
observed in the Kingston, Jamaica, Public Hospital, and 
on 121 of these patients full notes were taken. 

"The patients complained of numbness and burning 
heat in the palms and soles, often accompanied by cramps, 
worse at night and in wet weather. Impaired vision and 



22 PELLAGRA 

hearing were noted, and a feeling of constriction around 
the lower part of the chest. An eczematous condition ap- 
peared on the tops of the eyelids, the angles of the mouth, 
and the mucocutaneous margins of the nostrils; the lips 
were usually red, and the palms hot to the touch and 
hyperemic. Later, motor pains of upper and lower ex- 
tremities appeared. Pain was constant, especially of the 
feet. Emaciation developed with the progress of the dis- 
ease. Pigmentation of the palms, lips, and soles was pres- 
ent; respiration was impaired, and death ensued from paral- 
ysis of the respiratory muscles. Death was rare, recov- 
ery being the rule. 

"Soreness of the mucocutaneous borders, i. e., eyelids, 
lips, urethra, anus, vulva, etc., was almost the first symptom. 
Wasting and contraction of the muscles was very marked 
in extreme cases, the 'claw hand' and foot being pro- 
nounced features. ... In the last stage, when the 
patient is greatly wasted, there may be delusions with 
feeble attempts at violence. In this condition they may 
be committed to asylums. 

"The eyelids are red and irritated; a slightly eczematous 
condition develops at the corners of the mouth and round 
the margin of the nostrils, with a fine branny desquama- 
tion. . . . The lips and buccal cavity are hyperemic, 
and there may be loss of surface epithelium on the tongue. 
Palms and soles are hypermic, due to dilated arterioles, 
and later they are deeply pigmented, the color varying 
from brown to intense black. The gait is typically ataxic. 
The disease attacks both sexes, youths and adults." 
(Marie.) 

For quite a while this was called "Strachan's disease/' 



GENERAL CONSIDERATIONS, HISTORIC AND OTHERWISE 23 

but, in the light of present knowledge, we may safely class 
it pellagra. 

Dr. Patrick Manson, in writing on " beriberi " (Tropical 
Diseases), takes issue, and in a foot-note writes as fol- 
lows: "Dr. Strachnan has described a form of multiple 
neuritis which he calls malaria. The disease is endemic, 
and very common in Jamaica. It differs from beriberi, 
inasmuch as it is not attended with edema, is frequently 
attended with implication of the cranial nerves, and is 
rarely fatal. We have no account of any similar disease 
of other tropical countries. . . ." 

Dr. G. L. Manning, the medical superintendent of the 
lunatic asylum at Barbadoes, has reported similar cases 
there, and thinks the trouble contagious, recommending 
the isolation of all patients. 

Dr. D. J. Williams, of Kingston, Jamaica, writes, "The 
existence of pellagra was recognized here about twelve 
years ago, but as then it was unknown in the West Indies, 
and the correctness of the diagnosis was questioned, and 
the erythematous condition of the exposed limbs at- 
tributed to sunburn. 

"Four or five years ago the disease was very prevalent. 
. . . With generous diet, rest in bed and tonics, the 
majority improved temporarily; others made no improve- 
ment, but suffered from chronic diarrhea, progressive 
weakness and emaciation, until death ended the scene." 
- Mexico, Brazil, Uruguay, and the Argentine Republic 
have had their share of pellagra, though from some of these 
countries the reports are hazy and indefinite. 

A graphic account concerning conditions dietetic and 
pellagrous in Yucatan, Mexico, has been furnished by Dr. 



24 PELLAGRA 

G. F. Gaumer of Izamal. He writes, " In 1882, in Yuca- 
tan, locusts destroyed vegetation, especially Indian corn. 
Corn being the only cereal used in Yucatan for bread, 
famine seemed inevitable, until the merchants began to 
import it from New York. This importation continued 
till 1 89 1, when the country had recovered from the de- 
vastation of the locusts. The imported corn was brought 
in the holds of vessels as ballast. By reason of exposure 
to heat and humidity on the voyage, the corn underwent 
fermentation and became unfit for food. The constant 
eating of this spoiled corn led to the slow development of 
pellagra. 

"The disease was confined to the lower and middle 
classes, who were obliged to purchase the cheapest corn in 
the market. The wealthy classes escaped, as they did not 
eat the imported corn. For the next ten years, 1891 to 
1 901, Yucatan produced enough corn for home consump- 
tion, and cases of pellagra no longer developed. The 
old cases ran their course fatally. From 1901 to 1907 the 
corn crops were almost total failures, and corn was again 
imported in larger amounts than ever before. Mobile 
and New Orleans were the chief sources of supply, but some 
came from Vera Cruz — all by water. Again pellagra be- 
came epidemic, but was not confined to the middle and 
lower classes as before. It had been found more profitable 
to raise hemp than corn, so all classes used the imported 
cereal. Consequently, pellagra spread alike among the 
rich and poor. At the close of 1907, 10 per cent, of the 
inhabitants were the victims of pellagra, and in August, 
1909, not less than 8 per cent, of the population had the 
disease." 





Egyptian case of pellagra. Note the " breast-plate " on exposed surface 

of breast. 




fe 



African case of pellagra, showing erythema on back of neck and shoulders. 



CHAPTER II 
PELLAGRA IN THE UNITED STATES 

As early as 1863 two cases were recognized in New York 
and Massachusetts — one by Dr. John P. Gray, of Utica, 
New York, and one by Dr. Tyler, of Somerville, Mass. 
It might not be amiss to mention that, at this time, there 
were reports of a supposed epidemic of pellagra near 
Halifax, Nova Scotia, though details were lacking and the 
diagnosis was only inferential. 

We now come to the discussion of certain conditions in 
some of the large detention camps or prisons during the 
late Civil War. More particularly, may we revert to 
Libby Prison, at Richmond, Va., and the Anderson ville 
prison, both used for Federal prisoners, though the for- 
mer was mainly for officers, and the latter for private 
soldiers. 

The war was dragging its weary length, both sides 
were embittered by the internecine strife, and both had 
severely taxed their resources to carry on the conflict. 

Far be it from the writer to enter into any discussion 
of any issues involved, or the wisdom or unwisdom of meas- 
ures employed in the management of these prisons. 

It is well known that the mortality was frightful. 

Right at that time the South was staggering in the 
struggle for governmental existence; all sustaining indus- 

25 



26 PELLAGRA 

tries were paralyzed, and it was a problem to find suffi- 
cient sustenance for her own soldiery and people, with the 
added burden of providing for all these prisoners. Corn 
was the principal, sometimes the only available, food to 
be had, and the facilities for transporting and preserving 
it were far from ideal. 

The writer has been able to interview several veterans of 
intelligence, who were at Andersonville during that dread- 
ful period — two who were guards and one who was a 
prisoner — and the details, even softened by all the years of 
healing time, were harrowing in the extreme. 

The hygienic facilities were primitive, nor was much 
effort made to enforce those supposed to be in vogue. A 
major part of the diet was of corn products, some of which 
had been through more than one wetting and drying, and 
which were mouldy or wormy. The water was bad, the 
surroundings were depressing, and these poor men suf- 
fered the pangs of illness, to which were added the sorrows 
of nostalgia — that dread of wanderers far from home. 

Little wonder it was that they sickened and died, and 
fortunate the few who, " by reason of strength,'' were 
able to withstand the noisome odors, the scanty and un- 
wholesome food, and the depressing influences on every 
side. 

Dr. J. W. Kerr, of Corsicana, Texas, has written a 
report of some of the conditions, and, in the light of a 
clearer retrospective vision, he believes that pellagra was 
the evil agent responsible for many deaths. 

The veterans mentioned above have told the writer 
how the men had a supposed eczema; how tney loathed 
their food, and how it served them after it was eaten; how 



PELLAGRA IN THE UNITED STATES 27 

their skins were rough and hard, and how their hands were 
sore and cracked; how their bowels were chronically loose 
— so much that there was a pathetic joke that a prize would 
be given any prisoner having a solid fecal movement. 
Upon this weight was superimposed the melancholy 
deepening into the different forms of dementia, where 
indifference to fate brought about increased carelessness 
as to common rights in their adversity, or hygienic pre- 
cautions that would have ameliorated the common lot. 

Whether or not this was really pellagra will probably 
not be positively known, but there is a widespread belief 
among students of history that such was the disease which 
brought to an untimely end many of the flower of the 
Federal army. 

From 1864 up to 1883 we hear nothing more of this 
disease, when one case was reported by Dr. S. Sherwell, 
of Brooklyn, New York, in a Genoese sailor. 

Dr. H. N. Sloan asserts that pellagra was diagnosed in 
the South Carolina Asylum at Columbia in the early 
'70s, but no written nor printed record has been found. 
Dr. D. S. Pope, of Columbia, as quoted by Dr. Babcock, 
is satisfied that at least two cases occurred in the South 
Carolina penitentiary in the middle '80s. 

In 1889, Dr. Bemis, of New Orleans, left a written 
diagnosis of a case in a white woman at the Charity Hospi- 
tal in that city. 

. During all these years it is practically certain that 
pellagra existed plentifully in the Southern States under 
various diagnoses. Such puzzling cases were diagnosed 
as unusual manifestations of tuberculosis, syphilis, malaria, 
acute delirium, dementia, melancholia, hook-worm, ec- 



28 PELLAGRA 

zema, dermatitis exfoliativa, and others. In some quar- 
ters, somewhat removed from the medical centers, where 
the niceties of diagnosis were hardly appreciated, some of 
the appellations applied to undoubted cases of pellagra 
would have been humorous, had they not been fraught 
with dangerous consequences for the sufferers. " Ele- 
phant itch," " seven-years itch," " country scurvy," 
" poison oak or ivy," but, most of all, eczema, that medi- 
cal mantle that covers so many slipshod diagnoses. 

The writer well remembers a case occurring in a mulatto 
girl twenty-two years ago, the manifestations of which he 
was unable to understand at the time, but which seem 
plain in the light of present knowledge. 

This girl, an intelligent school teacher, twenty years of 
age, was treated for diarrhea, indigestion, and nervous- 
ness during the months of March, April, and May. Her 
diarrhea and indigestion improved, but she remained ner- 
vous and averse to work all the summer. That fall and 
winter she seemed well, but in the following March her 
diarrhea returned worse than before, with the other at- 
tendant symptoms magnified. She also had an " ecze- 
matous " eruption on her hands and feet, symmetric and 
sunburned in appearance. She was much depressed 
mentally, so that she gave up her school, and changed 
her home, with the hope that new environments would 
help both her digestion and mental condition. She seemed 
to improve, and, by November, she returned, apparently 
well, though reduced in weight. 

The following March showed a renewal of every symp- 
tom in aggravated form, with rapid emaciation, frequent 
involuntary stools, hands and feet first erythematous, then 



PELLAGRA IN THE UNITED STATES 29 

raw and weeping, a settled melancholy, and death in the 
early part of May. 

This patient was seen by some well-posted physicians, 
but none of them were able to make a diagnosis. 

In 1900, the writer saw two fatal cases of this sort — 
one in his own practice and the other with a confrere — 
both of whom gave a history of recrudescences and ex- 
acerbations through several preceding years. 

All of these patients were in agricultural districts, were 
in limited circumstances, and had always eaten corn-meal. 

With the slight exceptions mentioned, the pellagra situa- 
tion remained in statu quo until 1902, when Dr. H. F. 
Harris, of Georgia, reported a case. 

As has so frequently happened to the prophecy of a 
prophet in his own country, the report of Dr. Harris ex- 
cited but little comment, and practically nothing more 
was heard of pellagra until about 1907, when independent 
reports from various sections of the South began to come 
in. Medical officers of asylums in South Carolina and Ala- 
bama reported such cases with scientific exactness, and in 
the summer of 1908 Drs. Babcock and Watson, of Colum- 
bia, S. C, went to Italy to study the disease. 

On their return, they were able to positively identify it, 
and, as they wrote of it, others began to remember cases 
in practice of past years; cases not diagnosed; cases whose 
deaths were hard to explain. 

In rapid succession, pellagra was then reported from 
Wilmington, Morganton, and Charlotte, N. C; Augusta, 
Milledgeville, and Atlanta, Ga.; Tuscaloosa and Mont- 
gomery, Ala.; Columbia and Charleston, S. C; and many 
other places in a number of states. 



30 PELLAGRA 

In 1909, the people of the South, as well as the officials 
of the Public Health and Marine Hospital Service, who 
had already made valuable investigations, began to wake 
up to the gravity of the situation, and in November, 1909, 
a Conference on Pellagra was held under the auspices of 
the South Carolina State Board of Health at the State 
Hospital for the Insane, Columbia, S. C. Another Con- 
ference on Pellagra was held at the same place in October, 
191 2, which assumed a national importance. 

At these conferences representative men, physicians, 
publicists, students of sociologic problems, and citizens of 
every walk of life attested their interest by their presence. 

The discussions and deliberations as to the etiology, 
pathology, and clinical aspects of this disease will receive 
attention; suffice it to say, that the ear of the American 
people was reached, and pellagra, as an American problem, 
was driven home to the most skeptical. 

Since that time, up to the present writing, the question 
has been not one of fact, but of degree. At that time 
about 1000 cases had been reported from thirteen states, 
but, as the returns have come in, practically every state in 
the Union reports within its borders either positive or sus- 
pected cases. 

In some of the states the existence of pellagra has received 
much more than passing notice, as attested by many and 
valuable contributions as to its features as it has appeared 
in different localities. 

Dr. J. N. Hewett, of Lynnhaven, Va., and Dr. Beverly 
Tucker, of Richmond, have studied many non-institutional 
cases in their and adjoining states, being convinced that it 
exists to a far greater extent than is commonly realized. 



PELLAGRA IN THE UNITED STATES 31 

In only a very few states is the occurrence of the disease 
required to be reported, and in the absence of records of 
cases it is quite impossible to know how much of the 
malady exists; and that of the states in which the disease 
is notifiable the only one which is really getting reports is 
the state of Mississippi, where the number of cases reported 
during the last three months of 19 14 were as follows: 

October, 1914 824 cases. 

November, 1914 603 cases. 

December, 1914 418 cases. 

Among the states where pellagra has assumed formidable 
proportions are Virginia, North and South Carolina, 
Georgia, Florida, Alabama, Mississippi, Louisiana, Texas, 
Tennessee, Illinois, Missouri, Kentucky, and Arkansas. 
In others, the health officers are on the watch for sporadic 
cases, but do not seem to locate very many. 

That some of these returns are incomplete is in many in- 
stances shown on their faces. For instance, Florida re- 
ported only 50 cases up to 19 n in the whole state. The 
writer alone had, in that year, seen 18 cases from that 
state that came to this city from Florida for treatment. If 
that many came to one city for treatment, the inference is 
plain that there must have been many more than 32 who 
remained at home. 

Again, there is a sentiment springing up in some quar- 
ters that pellagra is a " loathsome disease," and one in 
which the afflicted pellagrin does not wish the public to 
know its presence. 

A short time ago the writer treated a widow lady, who, 
when she was informed that her trouble was pellagrous, 



32 PELLAGRA 

earnestly requested that her son be not informed what 
was the matter. She seemed to feel ashamed of her ail- 
ment, nor could she be reassured by any persuasive arts 
of her medical attendant. 

A lady from Florida recently was in Atlanta for treat- 
ment, and, upon the rumor that she had pellagra becoming 
rife in the family hotel where she boarded, some of the 
boarders rose in arms, insisting that if the proprietress 
did not ask her to leave, they would seek other homes. 
She was asked to leave, and did so. 

Many of the public hospitals and sanatoria have passed 
rules excluding pellagrins, and can it be wondered that 
these unfortunate invalids use every effort to keep from 
general knowledge the real nature of their malady? 

In more than a few instances the statement to an in- 
quiring patient that pellagra was the diagnosis has brought 
forth expressions of either incredulity or indignation, fol- 
lowed by impassioned appeals that no one be informed of 
the nature of the illness. 

Many times the patient, with an assumed skepticism, 
goes to the family physician, carrying the plainly-implied 
desire that the diagnosis be not verified. The physician, 
being anxious to give his troubled questioner the benefit 
of every doubt, admits that perhaps there is a mistake, 
and, upon this figment of uncertainty, the patient boldly 
asserts that a mistake has been made, that only an " ec- 
zema " causes the eruption, that some dietetic errors are 
responsible for the gastro-intestinal manifestations, and 
that something else is behind the nervousness. 

To place this patient in the pellagra column would, if 
known, excite a stormy protest. 



PELLAGRA IN THE UNITED STATES 33 

This picture will bring to many readers the memory 
of just such a state of affairs, and can we wonder that 
reliable statistics are hard to obtain ? 

The writer, from exhaustive inquiry among health 
officers, asylum superintendents, and other interested 
observers, believes that a present estimate of forty thousand 
pellagrins in the United States is not far from correct. 

"Like appendicitis, the disease is now better diagnosed — 
hence the seeming rapid increase; although, for some un- 
known reason, there is probably a real increase, but not so 
great as it appears." (Babcock.) 

It would be puerile for any of our states, no matter how 
far north, with a "holier than thou" attitude, to dis- 
claim its presence, or to minimize the reality of the prob- 
lem now at our doors. 

Not so many years ago the late Grover Cleveland ut- 
tered that epigram, " A condition and not a theory con- 
fronts us," and well may we apply those words to the 
visitation of this malady that, unless checked, will bring 
sorrow to many hearthstones and disquietude to many 
municipalities and states. 



CHAPTER III 
A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 

It is with a sense of trepidation that the writer enters 
into the discussion of the etiology of this disease. That 
spoiled maize was an etiologic factor was suspected by 
Casal, who, in 1762, attempted to elucidate the causal 
relationship between the corn and the " mal de rosa," 
as he dubbed it. 

This suspicion remained somewhat quiescent, though not 
entirely absent, until Mazari formulated a theory that the 
disease was brought about by the lack of certain nutritious 
qualities in corn. 

About this time, two schools of thought arose, the one 
espousing the " Zeist " theory (from Triticum spelta, or 
Zea Mays), the other opposing it. 

For many years a spirited, sometimes acrimonious, 
battle raged between these two schools, the echoes rising 
and falling like the swell of an ocean, as greater or lesser 
minds engaged in the wordy conflict. 

Had this chapter been written in 191 2 or 1913 the writer 
would have hesitated in devoting much space to the "Zeist" 
theory. At present, however, the trend of opinion is de- 
parting from the belief that pellagra is transmitted by a 
winged, blood-sucking insect, and is leaning more toward 
the idea of its etiology lying in an unbalanced diet con- 
34 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 35 

taining an excessive proportion of corn or corn products, 
with other cereals and vegetables. 

For this reason it is still of interest to study the early 
history of maize, its distribution, and food consumption. 
The chemistry of spoiled and sound corn also will be con- 
sidered. 

Maize is a plant of the tribe Maydeae, of the order 
Graminese or grasses. It is unknown in the native state, 
but is probably indigenous to tropical America. Small 
grains of an unknown variety have been found in the 
ancient tombs of Peru, and Darwin found heads of maize 
embedded on the shore of Peru at 85 feet above the pres- 
ent sea level. 

Bonafous, however (Histoire naturelle du mats), quotes 
authorities as believing that it originally came from Asia, 
and maize was said by Santa Rosa de Viterbo to have 
been brought by the Arabs into Spain in the thirteenth 
century. A drawing of maize is also given by Bonafous, 
from a Chinese work on natural history, dated 1562, a 
little over sixty years after the discovery of the New World. 
It is not figured on Egyptian monuments, nor was any 
mention made of it by Eastern travelers in Africa or Asia 
prior to the sixteenth century. 

Humboldt, Alphonse de Candolle, and others, however, 
do not hesitate to assert that it originated solely in America, 
where it had been long and extensively cultivated at the 
period of the discovery of the New World, and that is the 
generally accepted modern view. 

Passing the purely botanical aspect of the stalk and 
outer covering of the grain, or husk, which does not con- 
cern us here, we find that Indian corn is a very nutritious 



36 PELLAGRA 

article of food, being richer in albuminoids than any other 
cereals when ripe (calculated in the dry weight). It can 
be grown in the tropics, from the level of the sea to a height 
equal to that of the Pyrenees, and in the south and mid- 
dle of Europe, but cannot be grown profitably in England. 
It is extensively grown throughout India, and is the most 
common crop throughout South Africa, where it is known 
as mealies, being the staple food of the natives. 

As an article of food, maize is one of the most extensively- 
used grains in the world. It contains more oil, too, than 
any other cereal, ranging from 3.5 to 9.5 per cent, in the 
dried commercial grain. 

Sound, matured, and well-dried corn is one of the most 
available, as well as most nutritious, of the foods offered 
the human race. Under proper methods of transportation 
it can be hauled an indefinite distance without deteriora- 
tion; and, when properly gathered and marketed, it will 
remain sound and wholesome for years. 

On the other hand, no grain is more susceptible to un- 
sanitary influences or careless handling. 

That the eating of spoiled corn has made a decided im- 
press on the language of the Italians may be judged by the 
names given in different dialects to express its odor — scagn, 
mttffito, pati, sobbolli, verdet, butta, arbolli, smaserido, rotnat- 
ico, mofflet, etc. 

On gross examination by the ordinary observer, spoiled 
corn may be distinguished by its cracked or wrinkled hull, 
its color of old gold, its lack-luster appearance with embryo 
enlarged, blackish, and showing through the surface like a 
ship in a fog. It nearly always shows external spots of a 
brownish or greenish color like verdigris. 






A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 37 

If the grain is cut in half and examined, the perisperm 
shows brownish, and the embryo a dingy black, instead 
of the white of good grain. The mass of the perisperm is 
often eaten away, leaving a little cavity in which is found the 
coleoptera nesting there, and a fine dust can be shaken out 
of the grain. These coleoptera are called " corn weevils " 
by the laity, and corn so affected is considered unfit for 
human food. 

The embryo is nearly always atrophied, so that it does 
not fill out its normal place between the perisperm and the 
hull of the caryopsis. Sometimes the outward appear- 
ance of the grains seems normal, but there can be noticed, 
on close inspection, little eroded points scattered over the 
surface, favoring the development of some of the moulds. 
From this also comes a greenish dust, which seems to 
penetrate the interior of the grain. In many grains the 
appearance of the moulds and the acarus farince coincide. 

The meal made from spoiled corn is not always easy 
to detect, unless it is decidedly bad. When much dam- 
aged, it gives off a " musty odor/' sometimes slightly 
aromatic, and has a bitter taste. 

Several tests for spoiled corn are mentioned by Marie, 
which are said to be fairly conclusive. He says, if some 
grains of spoiled corn are digested in 90 per cent, alcohol, 
their grayish-yellow color changes to an intense red, the 
alcohol becomes red, and the color deepens with time. 
On the contrary, if the grain is sound, it does not change 
color, even if it remains in the alcohol for two months, 
though the alcohol becomes yellow. 

Again, if in a dilute solution of caustic potash the hull 
of the grain of spoiled corn becomes first reddish brown, 



38 PELLAGRA 

later all the solution becomes brown, and gives off a pene- 
trating odor of spoiled corn. The more the decomposi- 
tion of the corn has advanced, the more decided is the 
reaction. If this alkaline fluid is neutralized by tartaric 
acid, flakes of a coffee color are precipitated which have 
the odor of spoiled corn; these flakes are insoluble in 
water or ether, but soluble in alcohol. This reaction, 
according to Marie, can be obtained with both meal and 
bread made of spoiled corn, the reaction showing a lemon- 
yellow color. 

Following the experiments of this investigator, we find 
that the tincture of spoiled corn yields three substances. 
The first is, at ordinary temperature, a liquid of ruby red 
color, with a bitter taste, and an odor of decayed corn. 
It is soluble in alcohol and ether, but insoluble in water, 
in which it floats ; it becomes resinous when exposed to air, 
and does not yield a precipitate with the iodid of potash, 
nor with other metallic salts. With caustic potash and 
benzin it yields a bright yellow precipitate, and a drop 
of it on paper makes a greasy spot. This tincture contains 
the oily substance of corn, and may be called the red oil 
of spoiled corn. 

The second substance is a reddish brown, styptic and 
bitter, is soluble in ordinary alcohol, but in absolute alcohol 
it precipitates yellowish flakes, which dissolve quickly 
if a little distilled water is added. It is also insoluble in 
ether, and yields, when treated with iodid of potassium, a 
flaky precipitate; with sulphate of copper it becomes green; 
if treated with much water, it separates into two parts, one 
of which, insoluble, is precipitated in the form of a brown 
amorphous powder; the other makes a bright yellow 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 39 

solution. This interesting product is called pellagrocein, 
or the toxic substance of spoiled corn, and its toxic proper- 
ties are very marked. 

The third substance, when heated with ether, solidifies 
into a mass, which becomes hard on exposure to the air. 
It is soluble in diluted alcohol and in a solution of caustic 
potash, but in water, benzin, or absolute alcohol it is 
insoluble. When heated it becomes soft, and can be 
drawn out like wax. This is the resinous substance of 
spoiled corn. 

It may be interesting to note that the substances ob- 
tained from spoiled corn are analogous to those obtained 
from spurred rye, possessing the same oxytocic properties. 

A great number of micro-organisms have been found 
in spoiled corn by investigators on " both sides of the 
water," and it would not be profitable to enter into a de- 
scription of them all, but the more important will be 
considered. 

Sporisorium Maidis. — This is the best-known parasite 
of spoiled corn. Its isolation and description inaugurated 
a new era in the study of pellagra in Italy. Seen under 
the microscope, it is of a greenish color, resembling little 
globules, but not coherent. 

Balardini, who first isolated and experimented with 
this micro-organism, found that when eaten for a while 
by man, it would produce gastritis and diarrhea. 

It has been common knowledge among the laity for 
many years that " musty meal," or spoiled corn, would 
cause illness in man or beast; and the writer remembers 
how, when a lad, his mother lost many fine chickens from 
a mysterious malady, which was solved when the cook 



40 PELLAGRA 

was discovered to have been feeding the fowls on dough 
made from spoiled meal. 

Lombroso did not think this organism responsible for 
pellagra, however, because he could not find it often in 
Lombardy, but others have thought differently. 

Probably the most important fungus is the penicillium 
glaucum, which, while it forms on other grains besides 
corn, does not in them seem to produce the pellagra poison, 
and is not of itself toxic to the human system. 

It is observed in pendicular filaments, from which 
are developed many flaky conidia. These filaments com- 
pose the greenish-blue dust, which is often noticed on the 
grains of spoiled corn. It does not long remain on the 
surface, but, when the corn is not housed in dry quarters, 
seems to penetrate into it. 

Says Lombroso, " Pellagra does not come directly from 
the penicillium, but from the pellagrozeina (identical with 
strychnin), formed in the corn as a result of the action of 
the penicillium. 

Other micro-organisms of probably less importance are 
the oidium lactis maidis, eurotium herbariorum, sporothri- 
cum maidis, bacterium maidis, and the aspergillus glaucus, 
the last of which is found in the same conditions as the 
penicillium, but more rarely. 

The bacterium maidis has not been found alone in 
faulty meal, but has also been found in sound, and in the 
bread made from such meal. 

" In 1 88 1 Majocchi found a very motile bacterium in 
both sound and spoiled corn, but always in greater num- 
ber on spoiled corn — this micro-organism he called bac- 
terium maidis, and he thought he found it in the blood 




A Lombroso chicken." This fowl was fed for four weeks on spoiled 
meal. (Courtesy of Dr. H. P. Cole, Mobile, Ala.) 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 41 

of seven pellagrins in the first stage of the disease. Cu- 
boni, working with this micro-organism, found it con- 
stantly and abundantly on spoiled corn. He also called 
it bacterium maidis, and recognized its similarity to the 
bacterium termo, though it resisted a higher tempera- 
ture." (Marie.) 

According to most observers, this bacterium occurs 
more readily in damp or immature corn, its develop- 
ment being arrested by drying, though on each fresh wet- 
ting of the grain it can renew its development. This 
explains why corn can be partly " sweetened," and then, 
on exposure to dampness or other unfavorable circum- 
stances, can again become unfit for food. 

Cuboni thought that the intestines of pellagrins offered 
an exceptionally favorable soil for the propagation of 
these bacteria, while they did not thrive so well in the 
intestines of healthy individuals. 

Paltauf and Heider have concluded from their studies 
that the bacterium maidis is the original potato bacillus, 
transplanted to a new soil and christened with a new 
name. They are not alone in this view. 

As in other grains where there is a large percentage 
of starch, the saccharomycetes are numerous in spoiled 
corn, but fermentative processes are necessarily due 
to other causes, and may, to an extent, be ascribed to the 
bacterium termo. 

Much study has been given to the different moulds 
on spoiled corn, but not many observers in America have 
followed it up. To our painstaking friends, the Italians, 
we owe most of our information on this subject, though 
the French have not lagged far behind. 



42 PELLAGRA 

Monti and Tirelli, using the methods of Koch, have 
made some very interesting studies of this subject. They 
found fourteen different organisms, some of which have 
already been specified (one of them the potato bacillus 
under its own name), and they opine that none of these 
are capable of directly injuring the human organism, 
but all are capable of inaugurating decomposition in differ- 
ent cereals. None of these organisms flourish when the 
grain is kept dry, but require a certain amount of moist- 
ure, and, in some instances, a variable degree of heat, in 
order that they may develop. 

The penicillium glaucum will flourish at a lower tem- 
perature than most of the others, and consequently it is 
more often present. For this reason it has possibly re- 
ceived undue importance. 

Many experiments have been made with the bacterium 
maidis by Lombroso and others. Into white mice the 
alcoholic extract of corn-meal, infected with the bacillus, 
was injected. Doses of 0.5 c.c. were injected, producing 
coma, paralysis, and death at the end of about two hours. 

Here are some other experiments made by Lombroso 
and his contemporaries, as narrated by Marie: 

If cultures on polenta of one, two, six, and up to seven, 
days old are given to animals they become accustomed to 
it slowly; the initial diarrhea, which is the only symptom, 
may even cease; but cultures over four to five days old are 
refused, perhaps because of their bad and very pronounced 
taste. As a consequence of this nourishment, digestive 
troubles are produced, sometimes vomiting, almost al- 
ways diarrhea, but never derangement of the sensibilities 
or of the motor system. At the end of some days the 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 43 

weight begins to diminish, but then maintains itself within 
normal limits. The temperature is usually maintained at 
normal; in the first days only two cases showed a slight 
evening rise. 

The attempt to cultivate this bacillus on wheat bread met 
with little success; two pigs, fed for fourteen days with 
this bread, showed no change. 

An experiment was then made with the alcoholic ex- 
tract obtained from a culture on polenta twenty-five days 
old. The extract, prepared by Prof. Fileti, was injected 
into three dogs, under the skin of the back, in doses of 5 
per cent., 10 per cent., and 25 per cent, of the weight of 
the animal. The two dogs which had received the largest 
doses died two days later, after presenting the following 
symptoms: 

Paresis of the hind legs, almost continual tremor, gen- 
eral depression, which was rapid and progressive, gradual 
loss of voluntary motion, complete paralysis of the hind 
legs, mydriasis, slight increase of temperature, accelera- 
tion of respiration and pulse, insensibility, bloody diarrhea, 
and death with prolonged agonistic state. At the autopsy 
edema of a hemorrhagic nature in the hypogastric region 
and the extravasations in the spleen. 

The dog inoculated in the proportion of 5 per cent, of 
its weight exhibited at the beginning the same symptoms, 
but, at the end of the second day, his condition improved; 
however, the hind legs remained paralyzed, and the diar- 
rhea continued for several weeks with a remarkable dimi- 
nution of weight. 

In the case of two other dogs, intravenous injections, in 



44 PELLAGRA 

a proportion of 5 per cent, of body weight, caused death 
after the development of the above-mentioned symptoms. 

Injections into ten frogs, with corresponding doses, 
brought on death in three hours with paralysis, diffuse 
ecchymoses on the interior of the thighs and into the 
hypogastric region. Intravenous injections of the extract 
of sound polenta up to 10 per cent, had no evil conse- 
quences; the same may be said of the subcutaneous injec- 
tions made in double doses. 

After this somewhat lengthy discussion concerning corn, 
spoiled and otherwise, it will more interest the reader to 
plunge " in medias res" and give in more intelligible terms 
the theoretic, if not real, connection between maize and 
pellagra. 

Lombroso has been the high priest of the zeists, his 
arguments have been weighty and voluminous, and it has 
required a stout heart and a nimble wit to cope with him. 
Even since his death the material he left behind has proved 
the bulwark of the adherents of the maize theory as to the 
causation of this disease, and all that has been written or 
said has necessarily partaken of his arguments. 

Dr. C. H. Lavinder, in a logical and fair discussion con- 
tributed to the New York Medical Record, traces from an 
early period the doctrine adduced by Balardini as to 
" verderame "up to the present, and the writer makes ac- 
knowledgments for the use of these statements. 

The early views have been sufficiently covered, so the 
status of to-day may be given as follows: 

"I. It is declared that history and observation show 
clearly that the first appearance of pellagra, and its later 
dissemination followed, more or less closely, the introduction 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 45 

of maize culture into Spain and its gradual spread to 
France, Italy, and other countries of southern Europe. 

" II. It is declared that pellagra is found as an. endemic 
disease only in those countries where maize is grown, and 
extensively used as an article of diet by the poorer rural 
classes. It is of importance to note, on the other hand, that 
the area in which pellagra is found endemic is but as a 
spot upon the extensive area over which the maize is found 
under cultivation. There are vast tracts where maize is, 
and has been, grown as food for many years, and yet 
no pellagra has appeared. This is a matter of much import 
with regard to the etiologic r61e which spoiled maize is 
supposed to play. 

" III. It is declared that countries in which maize is not 
grown or used as food, or only exceptionally so used, 
even though contiguous to pellagrous sections, or actually 
surrounded by them, are free of pellagra." 

[Lombroso, Babes and Sion, and others have reported 
just such peculiar instances.] 

" IV. It is declared that a change of food, either among 
individuals, or groups of individuals, brings constantly a 
diminution or disappearance of pellagra, or vice versa. 
There are also many reported instances of this kind. Most 
writers allege that recovery may take place, or ameliora- 
tion occur in the condition of pellagrins, by removing from 
their diet all maize and maize products. The case of 
Corfu, in this connection, is regarded as such a notable 
instance that it will bear quoting. Typhaldos (whose 
study and contributions to the literature of pellagra have 
been previously mentioned) states, that pellagra was 
unknown in this island previous to 1857, and that up to 



46 PELLAGRA 

that time the inhabitants grew their own maize, which 
was of a fine quality, but, for economic reasons, the cul- 
ture of grapes became almost universal, and they began to 
subsist on the imported maize of very poor quality — that 
is, spoiled maize. Pellagra followed and became endemic, 
and he found, in 1866, 81 cases there." 

Lavinder next groups the various modifications of the 
maize theory in the following lucid manner: 

"I. The idea that maize, as a food stuff, is wanting in 
proper nutritive value. This conception is in reality no 
longer held, having been rather effectually discredited by 
many careful analyses of maize, which show that this 
cereal possesses high nutritive value, is rich in fats and 
nitrogenous substances, and is easily assimilable." 

The chemical analysis and statement of the dietetic 
value of corn in the beginning of this chapter show that 
the argument concerning the deficiency in its nutritive 
value is entirely fallacious. The writer, in some dietetic 
observations conducted several years ago, found that 
laboring men, on a diet of corn-bread alone, could for as 
much as a week keep squarely up to their standard of effi- 
ciency. He was unable, however, to keep them on this 
diet over a week, not that they were suffering from any 
physical infirmity, but simply because they desired to 
return to their regular " bill of fare," and the persuasion of 
the writer was not effective enough to control them. 

In food value it compares very favorably with rice, 
for example, which constitutes a staple article of diet 
among the numerous classes of people who do not suffer 
from pellagra. Pellagra is, moreover, not infrequently 
found among well-nourished individuals, and its symptom- 
atology is not that of inanition. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 47 

" II. The idea that good, sound maize contains certain 
toxic substances which cause pellagra. This is another 
view which has been largely discredited by the absence of 
pellagra in so many places where maize is, and has been, 
for long periods, extensively used as food. 

"It is also worth while to note that the gross distinc- 
tion between sound and spoiled maize, in the opinion of 
many able observers is not always easily determined. 
Maize, by reason of its high fat and nitrogen contents, 
seems quite subject to change under the influence of bac- 
terial growth, and grain which to all appearance may seem 
perfectly sound can nevertheless be shown to be spoiled 
or damaged to a greater or less extent.' ' 

The writer well remembers how, when a lad, he used 
to observe the care with which corn was prepared when it 
was " milling day/' how all nubbins or defective ears were 
rejected, and how the small ends of the ears were broken 
off, so that none but sound, well-matured corn was sent 
to be ground into meal. This custom obtained among all 
the farmers, for in those days the South raised its own food 
crops to a major extent, nor had the immense and fertile 
expanses of the " Golden West " assumed their position as 
" granary " for these states. The well- trained noses of 
farmers or housewives could detect the slightest foreign 
odor, and luckless was the miller who sent back musty meal 
in exchange for sound and wholesome corn. 

Under this old regime there was no pellagra in the 
South, nor did it ever appear until, under changed condi- 
tions, brought about by economic reasons, as happened 
in the island of Corfu, other crops took the place of corn — 
other crops that brought more ready money, and the West 
was called on, as was Egypt in the days of Pharaoh. 



48 PELLAGRA 

In the Western and Middle States, as corn became a 
staple article, the problem was not alone to transport and 
sell it, but to house it in the immense quantities in which 
it was produced. The consequence was, that in many sec- 
tions the corn was not permitted to mature in the fields, 
and await there until thoroughly dried before it was put in 
barns, but it was cut, and the corn on the stalks was 
" shocked " in the fields until it was convenient to mar- 
ket it. In this semi-exposed condition, subjected to all 
the varying changes of the weather, the corn waited some- 
times for weeks, and then, perhaps, just after a season of 
rain, or when the atmosphere was humid in the extreme, 
it was put in close cars, and its journey began. 

If, by good fortune, it reached its place of final marketing 
in wholesome condition, it had to run the gauntlet of 
different wholesale storage depots, of warehouses for the 
mills, where often dampness abounded, and micro-organ- 
isms found congenial environment for bountiful multipli- 
cation. 

Thus, the corn, that was originally one of Nature's best 
food-stuffs, under the blighting treatment forced by com- 
mercial necessity and economic exploitation, became an 
object of suspicion in many quarters, and in others practi- 
cally under the ban of conviction. 

This, in brief, is the present status of corn — the com- 
mercial article whose safety as food is now on trial. 

" III. The toxicochemical idea, to continue with Dr. 
Lavinder, that under the influence of parasitic growths 
(bacteria or moulds) maize may undergo certain changes 
with the formation of one or more toxic substances of a 
chemical nature (exogenous poisons). This idea has a 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 49 

host of adherents. It was established through the ad- 
mirable labors of Lombroso, who, as said, has been its 
great advocate and exponent, and it is perhaps to-day the 
most popular of all the various phases of the maize theory. 
It is not without critics and antagonists, however, and 
Lombroso 's experimental work and conclusions have been 
seriously called in question by many able students of the 
disease. 

" For instance, if we use the bacterium maidis as an 
example, we may put it that it is inoffensive per se, but 
releases from the corn, after the peculiar toxicochemical 
action, a ptomain that works the harm. 

" The whole gist of Lombroso's argument may be ex- 
pressed by the theory that in pellagra we are not dealing 
with a primary poison, but with an intoxication produced 
by poisons developed in spoiled corn through the action 
of certain micro-organisms in themselves harmless to man. 

" Now, while Lombroso experimentally produced several 
poisonous oils and tinctures from spoiled corn, as de- 
scribed previously, unfortunately he could not incriminate 
any particular micro-organism. Many other adherents 
have followed up these investigations, producing in ani- 
mals and fowls symptoms analogous to pellagra; but 
similar symptoms have also been produced by poisonous 
substances obtained in the same way from other cereals. 

" Voluminous reports of such experimental work have 
been adduced by Erba, Hausemann, Pellogio, Gosio, 
Ferrati, Mariani, Belmondo, Pelizzi, Tirelli, and others 
with practically the same findings. 

" It is of much interest in this connection to know that 
Babes and Manicatide succeeded in neutralizing the 



50 PELLAGRA 

toxicity of spoiled maize extract with the serum of cured 
pellagrins; and, from a series of carefully conducted ex- 
periments, concluded that the blood of pellagrins con- 
tains a substance which possesses the property of counter- 
acting the toxic action of the extracts of spoiled maize." 

The theory built up on this hypothesis has been ex- 
tensively tried out, and at present has but few adherents. 

"IV. The toxic infective idea, that from spoiled maize 
there are formed within the body certain toxic substances 
(endogenous). 

" Neusser advocated the view that under some cir- 
cumstances there is formed in maize, largely under the 
influence of the bacterium maidis, a certain ' receptive 
mother substance' which later, in the body, underwent a 
further change. Under other circumstances, however, he 
viewed the disease as a direct intoxication. 

" De Giaxa attributed great importance to the action 
of the colon bacillus on ingested maize. His idea seems 
to have been that the vegetating properties of this bacillus 
may become greatly modified on a culture medium of 
maize, and he alleges that he has shown the production, by 
the colon bacillus on maize media, of specific toxic sub- 
stances." 

The tendency to charge the colon bacillus with various 
" high crimes and misdemeanors " has not been con- 
fined to Italy or France, for one eminent American gastro- 
enterologist has recently proved to his satisfaction that 
the colon bacillus alone is the microscopic malefactor in 
the production of pellagra. 

Passing for the time from the discussion of spoiled corn 
and corn products as an etiologic factor in pellagra, we 
desire in fairness to present the other side. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 51 

In opposition to the "zeistic" doctrine there arose a 
school, especially in France, and a group of investigators, 
led by Landouzy, began to report cases of pellagra where 
it was claimed no corn had ever been ingested. 

This brought to the fore Roussel, that deep thinker and 
trenchant writer, who questioned their observations, dis- 
credited their diagnoses, and introduced the new term 
" pseudopellagra," which he claimed fitted their cases. 

The term pseudopellagra has been a source of much 
confusion in the literature of this subject, and by some it 
has been considered a haven of refuge for their opponents 
when hard pressed by the anti-zeists. 

Sir Patrick Manson takes a fling at it with the remark, 
" The disease is pellagra when it fits in with the orthodox 
theory and when it can be connected in any way with 
maize, but, when this is not possible, the disease becomes 
pseudopellagra." 

Ceconni, LeFrer, and several other French writers 
speak of the pellagrous syndrome, and call it the " morbus 
miseriae." They go so far as to contend that among 
alcoholics, and in certain cachectic conditions, more 
particularly among the insane, symptoms may arise 
so closely simulating pellagra, that such a diagnosis can be 
reasonably made. In other words, they go so far as to 
deny that this is a disease sui generis. 

The tendency to implicate some protozoal or animal 
parasite was first brought forward by Dr. Louis W. Sam- 
bon, lecturer on Tropical Medicine at the Liverpool School 
of Tropical Medicine, who was detailed for three months 
in Italy, where he studied pellagra. 

Dr. Sambon, by his researches on the sleeping-sickness, 



52 PELLAGRA 

and his tsetse-fly theory, which has since been proved, 
established his position as a student, whose views were 
worthy of respectful consideration. 

Briefly and without elaboration, the following is Sam- 
bon's theory: 

Pellagra is not due to maize, either good or bad, be- 
cause — 

(i) It is found in places where maize is neither culti- 
vated nor eaten. 

(2) It is absent from many places where maize is the 
staple food of the population. 

(3) It has in many places either decreased or become 
more prevalent without any change in the food or the 
people. 

(4) Its constant and peculiar distribution does not agree 
with the very irregular and ever-changing distribution of 
spoiled maize. 

(5) In over a century and a half, since the maize theory 
was first suggested, no one has been able to prove it. 

The belief that the disease has everywhere followed the 
introduction of corn cultivation is unfounded. Pellagra 
was first recognized as a specific disease in the beginning 
of the 1 8th century, but this does not prove that it was not 
prevalent long before that time. 

On the other hand, Dr. Sambon makes the following 
postulates to prove that pellagra is a parasitic disease 
because — 

(1) For years the person affected may present some 
seasonal recurrences, which can only be explained by a 
parasitic agent with alternating periods of activity and 
latency. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 53 

(2) It shows a constant and characteristic topographic 
distribution. 

(3) It shows a definite seasonal incidence. 

(4) Its symptoms, course, duration, morbid anatomy, 
as well as its theory, are similar to those of parasitic dis- 
eases. 

(5) Of two places almost contiguous, one may be 
affected, the other not. 

Again, he contends that pellagra is an insect-borne 
disease because — 

(1) It is limited, like malaria, sleeping-sickness, etc., 
to rural places, and more especially to the vicinity of 
certain water bodies. 

(2) It has a definite seasonal incidence — spring and 
autumn. 

(3) It effects, to a large extent, a certain class of people 
— the field laborers. 

(4) It is not contagious, and neither food nor water can 
account for its peculiar epidemiology. 

(5) Within its endemic centers it affects all ages and fre- 
quently whole families. 

(6) Outside its endemic centers only adults who have 
visited the infection areas present the disease, and fre- 
quently only one or two members in a family are affected. 

His bill of indictment against the simulium reptans is 
based upon the following proof: 

(1) Simulium is found in the torrents and sw^ft running 
streams of all pellagra districts. 

(2) Simulium has the peculiar seasonal distribution of 
pellagra (spring and autumn). 

(3) Simulium is found only in rural districts. It is 
unknown in towns and villages. It does not enter houses. 



54 PELLAGRA 

(4) Simulium explains most admirably the peculiar 
limitation of the disease to field laborers. 

(5) Simulium is the only blood-sucking insect which the 
British field commission has found in its visits to numerous 
pellagrous districts in Italy. 

(6) Simulium reptans, like anopheles maculipennis, has 
a world-wide distribution and explains the wide distribu- 
tion of pellagra. It is found wherever pellagra is found. 

(7) Simulium causes epizootics in animals in America 
and in Europe. 

(8) Professor Mesnil has found a protozoal organism in 
simulium. 

These statements from Sambon are given principally for 
their historic interest, for he has abandoned the "simulium 
theory." 

This simulium fly belongs to the diptera, or two-winged 
flies, belonging to the simuliidce family. 

The species located in America are the simulium venis- 
tum, and the simulium pecarum, the buffalo gnat. In 
Italy Sambon found three varieties — simulium reptans, 
simulium ornatum, and simulium pubescans. The last 
named were found in the greatest numbers. 

While the topographic conditions in many places in the 
United States are similar to those in Italy, where the 
simulium reptans abounds, this particular variety is not 
found out of Europe, with the exception of Greenland, 
according to the authority of Dr. L. 0. Howard, chief of 
the Bureau of Entomology, United States Department of 
Agriculture. 

Dr. W. D. Hunter, of the same department, says, " All 
the information at hand seems to show that in this country 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 55 

there is no apparent connection between pellagra and 
simulium. The centers where simulium is most abun- 
dant are along the Mississippi Valley, from Baton Rouge 
north to about Cairo, 111., and in New Hampshire, Maine, 
and New York. 

" From a priori considerations, if there is anything in 
the simulium theory, the centers of pellagrous infection in 
the United States should be in the localities mentioned 
rather than in the Southeastern States." 

Sambon's ideas, also, that pellagra is nearly always linked 
to a running stream are not proved by the experience and 
inquiries of the writer. Out of over 100 cases, where 
this phase of the probable exposure was carefully gone into, 
in only 15 was this environment positively brought out. 
Many were city dwellers, who had not been near streams 
at all; others had been raised in high and dry localities, 
and had never to their knowledge been bitten by " sand 
flies." 

The writer must confess that an original favorable con- 
ception of the " Sambon theory " has diminished in pro- 
portion as he has honestly endeavored to demonstrate its 
truth, until now he is unable to subscribe to it. 

That pellagra appears in those who have " never eaten 
corn or corn products " is continually being asserted. 
We can hardly open the pages of a medical journal without 
seeing some instance of this sort cited, where, with an icon- 
oclastic air, like the " three tailors of Tooly Street, who 
resolved that the earth was flat," the narrators seem to 
think the zeistic idea has been relegated to the limbo of 
discredited theories. 

A New Orleans observer has reported a case of pellagra, 



56 PELLAGRA 

which for quite a while seemed that it was going to prove 
an exception to Lombroso's doctrine. This pellagrin was 
a married woman, who had been raised in a section of 
country and in a family where corn was considered suitable 
food for horses and hogs, but not for people. She and her 
husband iterated and reiterated the solemn declaration that 
never in her life had she eaten any corn or any food made 
from corn, when accidentally the physician learned that 
she was addicted to the use of corn starch, eating a pound 
or more each day. 

This morbid appetite — amylophagia — is not very un- 
common, as may be judged by the fact that recently the 
writer has known of three cases at the clinic for internal 
medicine at the Atlanta School of Medicine. They were 
women — one white and two colored — and they admitted 
the craving with evident reluctance. 

That corn in many forms, as an adulterant and other- 
wise, enters into many articles of daily consumption is an 
undoubted fact. 

A miller recently described the former custom of adul- 
terating the cheaper grades of flour with " corn hearts," 
though he claimed the pure food laws had practically put 
an end to it. 

Dr. J. L. Campbell has called attention to the fact 
that most, if not all, of the inexpensive candies on the 
market have glucose as their base; also most of the table 
syrups contain this corn product. 

The breakfast cereals, a legion of which are constantly 
on American tables, contain more or less corn. We are 
served some food containing corn on our uprisings and our 
downsittings, so that it behooves no one to lightly say that 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 57 

he or she has never eaten this grain or anything made 
from it. 

Another theory, which the writer will incorporate in this 
work, is that brought forward by Dr. G. C. Mizell, that 
the cause of pellagra may be traced to the ingestion of 
" semidried edible oils." 

The writer does not subscribe to this theory, nor has it as 
yet received approbation in many quarters, but that the 
present-day views of pellagra may be adequately reflected 
in these pages, requires that Dr. MizelPs contentions be 
accorded a reasonable amount of space. 

Admitting the possibility of spoiled maize producing 
pellagra, he deems it impossible, unless the diet excludes 
all other food, especially fats. He further opines that 
the fat responsible for the trouble is linolin, a neutral fat, 
which is present to some extent in all semidrying and 
some drying oils. 

Lest this gentleman should be misquoted, his exact words 
will be used in the following paragraphs: 

" When linolin is consumed in large quantities it is de- 
posited in the tissues as linolin. When it undergoes oxida- 
tion poisonous products are formed. These oxidation 
products are suspected of producing the disease. This 
would necessarily mean that the disease is biochemic 
in nature. The amount of linolin consumed will depend 
on the percentage present in the oil and the amount of oil 
eaten. Some of the semidrying oils contain such a small 
percentage of linolin, it is probable that they would not 
be deleterious to health. This point needs to be em- 
phasized, as it appears that the quantity consumed is 
important. . . 



58 PELLAGRA 



a 



. Keep in mind that the import or production 
of oil does not mean that the oil is always eaten. Many- 
nations import, and some produce large quantities of oil 
of this class for commercial purposes. Germany is one of 
these. Germans are not an oil-consuming people. The 
chief substitute for animal fat in Germany is a non-drying 
oil, viz., cocoanut butter, the daily production of which 
is estimated at one hundred tons. A law requires the use 
of 10 per cent, of sesame oil in the manufacture of mar- 
garine. This amount I do not believe is sufficient to cause 
disease. It appears that it is necessary to introduce 
comparatively large amounts of linolin into the body in 
order to produce pellagra. 

" Below is given a table of the semidrying oils and 
nativity. Many minor oils are omitted, being less used, 
and only supplementing the more common: 

Oil of — Nativity. 

Cotton seed United States, India, Egypt, China, Russia, Brazil, 

Mexico, Japan, Turkey, etc. 
Sesame seed The Levant, India, Egypt, Java, Siam, Algeria, 

East and West Coast of Africa, South Rhodesia. 

Maize United States, Argentina, etc. 

Beechnut Manufactured in Europe in 1713, but not at present. 

Pinot Brazil and Guiana. 

Kapok East and West Indies, South America, Mexico, 

Africa. 

Brazil nut South America. 

Luffa seed East India. 

Rape seed India, Northern France. 

Pumpkin seed Austria, Hungary, Russia. 

Sunflower seed Hungary, India, China, South and Southwest 

Russia. 
Poppy seed Asia Minor, Persia, India, Egypt, South Russia, 

Northern France. 

"Poppy-seed oil is a drying oil, but contains a large 
percentage of linolin , and is an edible oil of extensive use. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 59 

Some of the above oils contain a low percentage of linolin 
and may be of no importance as an etiologic factor. 

" Laws regulating the importation of seed oils into 
some olive-growing countries have in recent years been 
enacted, so as to protect the home industry. Some coun- 
tries growing enormous quantities of oleaginous seed 
export the seed, and consume very little or none of the 
oil. Such is the case in China and Japan. 

" The people of Southern Europe are noted oil con- 
sumers. Italy is the second largest olive-oil-producing 
country in the world. Notwithstanding the enormous 
quantity of olive oil produced, much oil is imported. 
They are also the largest exporters of comestible oils in 
this region. 

" Large amounts of semidrying oils are imported. 
These are used at home, and exported as edible oils under 
various labels, and used to adulterate olive oil. These 
semidrying oils are cheaper than olive oil, hence are 
consumed by the poor. Cotton-seed oil was probably 
imported from Marseilles long before it was thought of in 
America. At the present time it is well known in the 
Italian market. 

" In recent years the demand has increased. It is 
stated that, when cultivation of lupines was introduced 
into certain regions, enabling the farming class to raise 
stock and dispense with maize as a food, pellagra disap- 
peared. It is probable that, instead of pellagra disap- 
pearing for the above-named reason, it was in reality due 
to a change from vegetable oil to animal fat consump- 
tion. . . . 

" My conclusion from investigation of the seed-oil indus- 



60 PELLAGRA 

try is that since 1817, when the first seed-crushing mill was 
put into operation in Marseilles, there has been an almost 
unlimited supply of seed oils. The habits of the various 
nations and individuals have alone operated in determin- 
ing the extent of oil consumption. Often the need of cheap 
food has determined the selection. Until the mills began 
crushing seed there was no pellagra in France. The 
peasantry were afflicted because the poor bought cheap 
food. In the United States the selection of edible fat 
was not determined by price until the cost of provisions 
increased about 1908. Until this date, purity of food 
was the determining factor to a great extent. It is true 
that the manufacturers have appealed to patronage from 
both standpoints. They made a cheap article for the 
poor and a high-priced article for those in better circum- 
stances. Dyspeptics have been shown that the oil is more 
digestible. The fastidious are told that the oil is pure 
vegetable oil, clean, and highly nutritious. The Pure 
Food and Drugs Act is stamped upon each package as a 
guarantee of purity and wholesomeness. The unsuspect- 
ing public, depending upon the guardianship of the govern- 
ment stamp, has adopted cotton-seed oil as a regular article 
of diet. Various cooking substances, without a single in- 
dication of their nature, are coming into the market with- 
out even the distributing agent being able (or willing) 
to name the contents of the package. People are con- 
suming these preparations without question because the 
government stamp is upon them. This being the case in 
our own country, who will doubt that the cheap comestible 
oils shipped (even as pure olive oil) into oil-consuming com- 
munities are made up largely of semidrying oil? 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 61 

"Note the progress of pellagra in the United States. 
It started in the South, where oil consumption began, and 
only after it began. Illinois should be placed with the 
South, both as to oil consumption and pellagra. More 
pellagra has appeared in California than any other western 
state. It is significant that she also consumes more 
cotton-seed oil. A map of cotton-seed oil consumption 
in the United States would serve as a map showing the 
geographic distribution of pellagra, except as affected by 
climate. Nations that have remained consumers of non- 
drying oils are not afflicted with pellagra. Some of them 
have eaten maize, just as the inhabitants of the United 
States have for several centuries, without having de- 
veloped pellagra. . , . 

" Experiments upon animals indicate that pellagra may 
be caused by eating less than one ounce of oil daily. If this 
is true, oil may be consumed for medicinal purposes in 
sufficient quantity to produce the disease, and olive oil 
should not be administered, unless of known quality.' ' 

This is a brief attempt to give the salient features of Dr. 
Mizell's theories, which, after three years, are still unproved. 

The conscientious narrator must admit that the cause of 
pellagra is still to a great extent an unsolved problem. 
The zeist doctrine is, on the present state of science, in- 
susceptible of direct proof or direct disproof. There are 
many reasons why it cannot be disproved. It is impos- 
sible to show that any person whose food partook of corn 
products ate only healthy corn. If the corn was originally 
healthy it might have been badly kept, or, if well kept, 
it might have been poorly treated after being ground into 
meal; or even the meal might have been wholesome, but the 



62 PELLAGRA 

bread or other articles of food made from it might have been 
allowed to become spoiled, or contaminated by contiguous 
agencies. So, when one has at any time eaten corn prod- 
ucts, there is a chance that it was not absolutely sound. 

The idea advanced some time back by the antizeists that 
pellagra was a "disease of poverty" has been exploded, 
though at present Dr. Goldberger is arguing somewhat 
along that line. The many cases in persons of wealth and 
refinement, where environmental conditions were all that 
could be wished, have effectually put an end to that chimera. 
The more positive doctrines, as collated by the late W. 
Bayard Cutting, Jr., may be enumerated as follows: 

(i) That which attributes pellagra to corn itself, not to 
spoiled corn. This explanation is inadequate. If corn is 
lacking in certain nutritive qualities — in gluten, in nitrog- 
enous matter — so is rice, which, nevertheless, does not 
produce pellagra. (The nutritive qualities of corn have 
already been favorably considered.) If corn contains a 
poison, how can so many nations consume it with im- 
punity? 

(2) That which admits spoiled corn as the cause, but 
thinks that the poison enters not as a toxin ready made, 
but as a bacterium {bacterium maidis). 

(3) Those which attribute the poison to other agencies 
than the penicillia — to the aspergilli, for instance, or to 
the bacterium maidis, or to a combination of these micro- 
organisms. 

(4) Those which, while admitting the direct poisoning 
from corn as one cause of pellagra, attach considerable 
importance to other elements — heredity, for instance, or 
the consumption of alcoholic liquors made from corn. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 63 

As far as Italy is concerned, they admit that the con- 
sumption of corn, and especially spoiled corn, is at the 
root of the disease, and official measures including this 
hypothesis are in motion, which will be covered later 
under the head of prophylaxis. 

Among predisposing etiologic factors poverty, no doubt, 
plays an important role. 

That unhygienic homes and surroundings, that ig- 
norance begotten of poverty, and continued by reason of 
poverty, may dwarf both the body and the intellect, im- 
pairing the normal resistance faculty, and making the 
body a more inviting host for the powers of disease; that 
cheap, often synonomous with adulterated, food should 
impair the digestive powers, laying foundations for various 
stomach and intestinal ills — all these can serve as un- 
doubted factors for the development of pellagra as well as 
any other toxic or infectious disorder. This has been con- 
clusively shown by the studies of the Thompson-McFadden 
Commission, whose labors will later receive extended com- 
ment. Let them be quoted as follows: 

"Another feature of our field work in 19 13 has been the 
survey of communities offering marked contrast in certain 
particulars. All the mill villages of Spartanburg County 
were found to be endemic centers of pellagra. All these 
villages have been using unscreened surface or pail privies 
for the disposal of human excrement. A careful survey of 
two other mill villages, one in Oconee County and the other 
in Chester County, S. C, failed to disclose any case of 
pellagra which had certainly originated in these villages, 
although cases which had originated elsewhere were present. 
In these villages every house was provided with a water- 



64 PELLAGRA 

carriage flush closet connected with a sewer, and this 
seemed to be their most important distinguishing charac- 
teristic. In the city of Spartanburg, S. C, the active foci 
of the disease were confined to those sections of the city 
in which unscreened surface or pail privies were in use. 
Of the 241 cases in the city of Spartanburg itself, for which 
data on disposal of sewage were available, it was found that 
230 were using unscreened surface or pail privies. In only 
1 1 instances, or 5 per cent, of the total, was a water-carriage 
system of disposal employed, and several of these cases 
arose in sections of the city where unscreened surface privies 
were in use by their neighbors, some of whom were pellag- 
rins. In certain hospitals for the insane we have ascer- 
tained that pellagra is usually most prevalent and persistent 
in the wards housing untidy patients." 

Apart from these considerations, however, poverty wields 
no specific influence. 

That heredity is a predisposing factor seems fairly 
well proved. The writer has records of 81 instances where 
pellagra was observed in the second or third generation; 
and at present has under observation 28 cases where 
pellagra has occurred (mostly fatally) in the parents or 
grandparents. 

One instance, where an infant was born of a pellagrous 
mother, was reported. It seemed that conception took 
place during a remission of the disease, but the confinement 
came on during the recrudescence. The infant lived 
only two months, never thrived, and its skin was harsh 
and dry during the whole of its brief life. 

The mother was treated a short time for the disease, 
but, after a period of improvement, ceased to report, and 
the final outcome of her illness was unknown. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 65 

The children of pellagrins also seem to fall an easy- 
prey to other diseases, notably those ailments of the 
alimentary tract. At the clinic for gastro-intestinal dis- 
ease at the Atlanta School of Medicine hardly a week 
passes but what some patient reports pellagra in one of 
the parents. 

In regard to race some interesting features have been 
observed. The Caucasian race seems more subject to it 
than the yellow or red race. Among the white race, also, 
the writer has noticed a preponderance among the blondes, 
perhaps because of their being more vulnerable to the 
sun's rays. 

Dr. Babcock's statement that in the South the disease 
is more common among the negroes than the whites has 
not been verified by the writer. That, when among the 
negroes, it more frequently attacks the women may be 
admitted, but, among several hundred observed during 
the last three years, the African race furnished only a 
small percentage. 

Dr. Bernard Wolff, of Atlanta, has adduced the novel 
theory that the Jews are practically exempt from pellagra. 
This brings up indirectly the question of heredity, for 
the Jewish blood is probably more free from admixture 
with other races than any other. Dr. Wolff has been 
able to locate only four pellagrins among this race, and 
the writer has never seen one. 

Sex is not supposed to exert any special influence, though 
about 65 per cent, of the cases coming under our obser- 
vation have been females. This has not been the ex- 
perience of others. It would appear that the nervous 
cases have largely been females. 



66 PELLAGRA 

Habits act on the principles of lessened resistance. 
Several alcoholics, and, strange to say, those who pre- 
ferred corn whisky, have been under observations with 
uniformly fatal results. 

One of the most fulminant cases the writer has ever 
seen occurred in a brawny mountaineer, who, as he ex- 
pressed it, was " a dear lover of corn liquor," and who 
lived only about three weeks after the pellagra was notice- 
ably developed. 

Venereal excesses, mental strain, pregnancy, and frequent 
child-bearing all act in the same way — no special predis- 
position, but lessened resistance. 

With few exceptions it does not attack the very young. 
Most writers claim that infants do not suffer with pellagra 
unless they are fed on spoiled corn products, and in this 
the writer agrees. 

No cases under five years of age have been personally 
known, and very few under ten. This malady seems to 
attack by preference those between the ages of twenty and 
forty — ages when they can be most useful to themselves, 
their families, and the community at large. When it at- 
tacks those over fifty, the duration is either short or a con- 
dition of dementia supervenes. 

Occupation was thought at one time to possess a large 
influence, but this idea is weakening at present. In Italy 
it has, of course, attacked the rural and agricultural popula- 
tion, as has been proved time and again. In America, 
however, and especially in the South, occupation has 
shown but scant influence. 

At present the writer has under observation several 
pellagrins, who are in easy, almost affluent circumstances. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 67 

One, an unmarried lady of about forty from an adjoining 
state, has been in her community a leader in civic reforms, 
an exemplar in hygiene, a stickler for correct manners of 
living. 

Another is a young woman, the petted darling of wealthy 
parents, whose every wish was always gratified, and whose 
surroundings carried every comfort that money could buy. 

Along with these cases come farm laborers, horny- 
handed, with the tan of sun and weather on their faces; 
operatives in cotton mills, pallid, with flat chests and 
anemic complexions; dusky-hued sons and daughters of 
Africa — all suffering from the same dread pellagra. 

The spring season certainly has an influence in bringing 
out the latent symptoms of this disease. How much 
actual influence the heat and sun have on indirectly caus- 
ing it by increasing parasitic growths, and hastening the 
putrefaction of poorly-kept food products, is only a matter 
of conjecture. That the actinic rays of the sun are in- 
strumental in producing the erythema cannot be gain- 
said. Furthermore, after the erythema is apparently 
healed, the sun, or even bright light, can bring it back 
again, is the experience of the writer and many others. 

Certain it is that pellagra is a disease of summer and 
warm weather, and that spring and summer exert a dele- 
terious effect, while cold weather is beneficial, is known to 
all who have had any experience with it. 

It has been claimed in Italy that humidity exerted a 
predisposing influence, and that the disease was more 
rife after a wet summer than a dry one. Such has not 
been noted in the United States, nor in the South, though 
the few years of our observation here are not sufficient for 
an intelligent opinion on this score. 



68 PELLAGRA 

Probably the most scientific and painstaking series of 
investigations as to the etiology of pellagra have been fur- 
nished by the Thompson-McFadden Pellagra Commission, 
a body of laborers made possible by the munificence of Col. 
Robert M. Thompson, of New York City, and Mr. J. H. 
McFadden, of Philadelphia. The funds thus supplied 
supported a research expedition for the study of pellagra in 
the United States, the members of the body being one 
designated by the Surgeon- General of the Army, one by the 
Surgeon- General of the Navy, and one by the authorities 
of the New York Post- Graduate Medical School. The 
commission was constituted as follows: Captain J. F. Siler, 
Medical Corps, U. S. Army, representing the Medical 
Corps of the U. S. Army; Passed-Assistant Surgeon P. E. 
Garrison, U. S. Navy, representing the Medical Corps of 
the U. S. Navy, and Dr. W. J. McNeal, Professor of Bac- 
teriology and Pathology, New York Post-Graduate Medical 
School, representing that institution. In the spring of 19 12 
the Bureau of Entomology of the U. S. Department of 
Agriculture detailed Messrs. A. H. Jennings and W. V. 
King to aid the commission by investigating the possible 
etiologic relation between insects and pellagra. 

A field headquarters was established in the South early 
in June, 1912, and, in collaboration, biologic, pathologic, 
and chemic studies were undertaken in the laboratories of 
bacteriology, pathology, and pathologic chemistry of the 
New York Post-Graduate Medical School under the super- 
vision of Dr. Jonathan Wright, Director of Laboratories, and 
Dr. W. J. McNeal, a member of the commission. Other re- 
searches along these lines were carried out by Drs. 0. S. 
Hillman, R. M. Taylor, V. C. Myers, and M. S. Fine. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 69 

For reasons considered sufficient, Spartanburg, S. C, and 
the county of the same name were made field headquarters, 
and the disease was there studied most intensively. The 
epidemiologic investigations have led to the accumulation 
of a very large mass of data concerning the occurrence and 
distribution of pellagra in Spartanburg County and city, 
in regard to the cases themselves and their conditions in life. 

As a fitting corollary to the field work was laboratory 
work in New York, which was accomplished by sending 
patients suffering from this disease from the field headquar- 
ters in South Carolina to the Post- Graduate Hospital in 
New York City. 

It would be impracticable to include all of the interesting 
data furnished by these painstaking and conscientious 
gentlemen, but the several conclusions will be given. 

Summary of first "Progress Report" covering work of 

19*3 : 

"(1) The supposition that the ingestion of good or spoiled 
maize is the essential cause of pellagra is not supported by 
our study. 

"(2) Pellagra is, in all probability, a specific infectious 
disease communicable from person to person by means 
at present unknown. 

"(3) We have discovered no evidence incriminating flies 
of the genus Simulium in the causation of pellagra, except 
their universal distribution throughout the area studied. 
If it is distributed by a blood-sucking insect, Stomoxys 
calcitrans would appear to be the most probable carrier. 

"(4) We are inclined to regard intimate association in the 
household and the contamination of food with the excretion 
of pellagrins as possible modes of distribution of the disease. 



70 PELLAGRA 

"(5) No specific cause of pellagra has been recognized." 

In the last report of this Commission, published in the 
Archives of Internal Medicine, January, 1915, a number of 
later conclusions are adduced. 

A synopsis of their statistics as to age of pellagrins is as 
follows: "Pellagra was absent or very rare in children under 
two years of age, only very slightly prevalent for the five 
years following puberty in both sexes, and only slightly 
prevalent in adult males under fifty years of age. On the 
other hand, it was enormously prevalent and severe in 
females from twenty to forty years of age, somewhat less 
prevalent and nearly always mild in children of both sexes 
from two to ten years of age, and almost equally prevalent 
in old people of both sexes. These features of the age and 
sex distribution are believed to be due in part to differences 
in physiological resistance to pellagra and in part to differ- 
ences in frequency and extent of exposure to the disease, 
especially by proximity to or association with other pellag- 
rins." 

Summary of last report: 

"(1) The geographical distribution of pellagra in Spartan- 
burg County, S. C, has been uneven, the morbidity being 
much higher in and near the large centers of population 
and especially in the cotton-mill villages. 

"(2) Pellagra was found to be about three times more 
prevalent in the white race than in the negro population of 
this county. This ratio is not regarded as a true measure of 
the relative racial resistance to the disease, but rather as 
the end-result of the influence of several factors. 

"(3) The substance of this paragraph in report has been 
given in synopsis above. 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 71 

"(4) The peculiarities of age and sex distribution are 
believed to be due in part to differences in physiological 
resistance to the disease, and in part to differences in degree 
and frequency of exposure to the causative factors, among 
which proximity to or association with pellagrins seems to 
be important. 

"(5) No direct relation of occupation to pellagra morbid- 
ity was discovered. Indirectly, by determining economic 
status and environment, occupation was found to have an 
important bearing on the prevalence of the disease." 

Up to the present the individual members of the Com- 
mission have not committed themselves to any statement 
as to the etiology of pellagra, though Dr. J. F. Siler, in a 
carefully worded communication, writes: "We feel that when 
all the information which we have collected has been brought 
together and analyzed, that it will indicate very strongly 
from the epidemiological standpoint that pellagra is a low- 
grade infection of some kind. We are inclined to believe 
that the primary lesions occur in the intestinal canal. We 
also feel very strongly that it is necessary that predisposing 
factors be considered in the etiology of pellagra, and one of 
the most important predisposing factors is diet (and nutri- 
tion) . We do feel, however, that it is not possible to explain 
pellagra from the viewpoint of a deficient diet alone." 

Pellagra and Potable Waters. — In a recent monograph 
of nearly 200 pages Alessandrini and Scala have presented 
a series of epidemiologic studies on pellagra, which led them 
to regard the disease as etiologically related to potable 
waters used in pellagrous sections. 

Their experimental work was conducted on guinea-pigs, 
rabbits, dogs, and monkeys. It consisted in the injection 



72 PELLAGRA 

and ingestion of colloidal solutions and gelatinous suspen- 
sions made from the potable waters; along with numerous 
variations in the diet of the animals, especially with refer- 
ence to a diet of maize. In some experiments they made 
additions to their solutions of certain salts, notably of cal- 
cium, sodium, and aluminum, for the purpose of testing the 
action of certain electrolytes on the colloidal silica or of the 
contemporaneous action of the two (that is, colloidal silica 
and electrolytes) on the organism. 

In an analysis and discussion of results the authors ex- 
press the conviction that they have produced in their ani- 
mals a chronic intoxication which not alone in essential 
features but even in details closely approximate pellagra as 
seen in man. This they assert is true not only of clinical 
phenomena, but also of morbid pathologic changes. 

This is their condensed argument: "Colloidal silica dis- 
plays more or less affinity for mineral salts, and from meta- 
bolic studies on dogs under experiment, without doubt, silica 
in the animal organism acts by accumulating mineral sub- 
stances, and produces in consequence a destruction of tis- 
sues. Therefore it seems to us, without doubt, that the 
silica fixes the mineral salts on the proteins of the tissues 
with a continuous, incessant action quite similar to the 
action of an enzyme or diastase." Continuing, they opine 
that "conditions exist in the formation of these compounds 
of protein substances with mineral salts by which the acids 
of such salts are liberated, because there is a tendency in 
said compounds to pass from the state of metallo-acido- 
protein to that of metals-protein." 

By further argument, analysis, and experimentation they 
arrive at their final conclusion that "pellagra is a malady 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 73 

caused by the forced retention of mineral salts, which, in 
turn, produces a liberation of acids in excess of the needs 
of the peculiar organism; or, in other words, pellagra is 
nothing more than a mineral acidosis with all of its con- 
sequences.' ' 

The writer has no special comment on these ingenuous 
arguments, simply including them to "make the record 
complete/ ' 

Elsewhere in this volume mention is made of the fact that 
at no time under the observation of the writer has a nurse 
or attendant of one or many cases of pellagra developed the 
disease. 

In a recent article (Reprint No. 203, Public Health 
Reports) Dr. Joseph Goldberger, Surgeon U. S. Public 
Health Service in Charge of Pellagra Investigations, re- 
marks: "In considering the significance of various institu- 
tional reports, it is to be recalled that at all of these insti- 
tutions the ward personnel, nurses, and attendants spend a 
considerable proportion of the twenty-four hours, on day 
or night duty, in close association with the inmates ; indeed, 
at many of these institutions, for lack of a separate building 
or special residence for the nurses, these live right in the 
ward with and of necessity under exactly the same conditions 
as the inmates. 

"It is striking, therefore, that although many inmates 
develop pellagra after varying periods of institutional resi- 
dence, some even after ten to twenty years of institutional 
life, and, therefore, it seems permissible to infer, as the result 
of the operation within the institution of the exciting cause 
or causes, yet nurses in attendance living under identical 
conditions appear uniformly to be immune. If pellagra is 



74 PELLAGRA 

a communicable disease, why should there be exemption of 
the nurses and attendants?" 

Dr. Goldberger has given the etiology of pellagra careful 
study, and his theories are worthy of consideration. They 
will be given verbatim: 

"The explanation of the peculiar exemption under dis- 
cussion will be found in the opinion of the writer in a differ- 
ence in the diet of the two groups of residents. At some of 
the institutions there is a manifest difference in this regard; 
in others none is apparent. 

"The latter would seem to be a fatal objection to this 
explanation, but a moment's consideration will show that 
such is not necessarily the case. The writer from personal 
observation has found that, although the nurses and attend- 
ants may apparently receive the same food, there is, never- 
theless, a difference, in that the nurses have the privilege — 
which they exercise — of selecting the best and the greatest 
variety for themselves. Moreover, it must not be over- 
looked that nurses and attendants have opportunities for 
supplementing their institutional dietary that the inmates, 
as a rule, have not. 

"In this connection brief reference must be made to two 
other epidemiological features of pellagra. It is universally 
agreed (i) that this disease is essentially rural, and (2) asso- 
ciated with poverty. Now there is plenty of poverty and 
all its concomitants in all cities, and the question naturally 
arises why its greater predilection for rural poverty? What 
important difference is there between the elements of pov- 
erty in our slums and those of poverty in rural dwellers? 
It is not the writer's intention to enter at this time into 
a detailed discussion of these questions; he wishes to point 



A DISCUSSION OF THE ETIOLOGY OF PELLAGRA 75 

out one difference only. The difference relates to the diet- 
ary. Studies of urban and rural dietaries have shown that, 
on the whole, the very poor of cities have a more varied diet 
than the poor in rural sections. 

"With regard to the question of just what in the dietary 
is responsible, the writer has no opinion to express. From 
a study of certain institutional dietaries, however, he has 
gained the impression that vegetables and cereals form a 
much greater proportion in them than they do in the diet- 
aries of well-to-do people; that is, people who are not, as a 
class, subject to pellagra. 

'The writer is satisfied that the consumption of corn or 
corn products is not essential to the production of pellagra, 
but this does not mean that corn, the best of corn, or corn 
products, however nutritious and however high in caloric 
value they may be, are not objectionable when forming of 
themselves or in combination with other cereals and with 
vegetables a large part of the diet of the individual. 

"In view of the great uncertainty that exists as to the 
true cause of pellagra, it may not be amiss to suggest that 
pending the final solution of this problem it may be well to 
attempt to prevent the disease by improving the dietary 
of those among whom it seems most prevalent. In this 
direction I would urge the reduction in cereals, vegetables, 
and canned foods that enter to so large an extent into the 
dietary of many of the people in the South, and an increase 
in the fresh animal food component, such as fresh meat, 
eggs, and milk." 

The etiology of pellagra is yet unproved, though the reader 
should remember that the time is not yet ripe to cast aside 
as worthless the tomes of written evidence gathered through 



76 PELLAGRA 

nearly two centuries by Italian and French investigators, 
and now being augmented by scores of able research workers 
on both sides of the water. 

The writer has not cast to the winds the "Zeist" theory, 
though agreeing in the main with the conclusions of Dr. 
Goldberger. He has endeavored, however, to give every 
side of the vexed question, permitting the reader to form his 
own conclusions. 

Lombroso said: "In pellagra, then, we are dealing with an 
intoxication produced by poisons developed in spoiled corn 
through the action of certain micro-organisms in themselves 
harmless to man." 

If to Lombroso's dictum of spoiled corn we add spoiled 
carbohydrates, the statement will come near embracing our 
latest and most reasonable theories as to the causation of 
pellagra. 



CHAPTER IV 

SYMPTOMATOLOGY AND CLINICAL COURSE OF 
PELLAGRA 

Seldom in the history of diseased processes has there 
been studied one whose symptoms and clinical history 
presented such a varied panorama as pellagra. 

Its many characteristics have placed it in quite a num- 
ber of categories covered by specialties in the different 
fields of medical endeavor. The gastro-enterologists have 
dwelt on the ever-present digestive disturbances, often 
the first noticeable manifestations of illness, the anorexia, 
the epigastric discomfort, the diarrhea, and all that train 
of gastro-intestinal ills. 

The dermatologists have noted the skin lesions, be- 
ginning with the simple erythema, and developing the 
various grades of dermal inflammation. Their contention 
has had the weight of " external evidence," for few cases 
of pellagra have there been who did not at some stage show 
an eruption of some sort. 

The neurologists and alienists have found in pellagra 
a fertile field for research and discussion. The nervous 
and mental symptoms cover a range extending from un- 
defined irritability and change of disposition to dementia or 
acute mania ; exhibiting abnormalities resulting from simple 
lack of poise up to organic nerve degenerations of fatal 
proportions. 

77 



78 PELLAGRA 

The surgeons, too, have figured in pellagra, for transfusion 
of blood from healed pellagrins or healthy donors has ex- 
cited wide comment, and at one time seemed to promise 
a therapeutic solution. Even cecostomy and appendi- 
costomy have been advocated for the toxemia, though few 
pellagrins have consented to such an ordeal, seeming to 
prefer the ills they have rather than fly to those they know 
not of. 

To attempt to follow the course of pellagra from one 
viewpoint, or to permit it to be narrowly classed as a mani- 
festation of one organ or set of organs, would be erroneous. 
It would be unjust to the patient, unfair to the honest 
student, and productive of endless confusion. 

In addition, pellagra does not always appear in the same 
form. There are variations, brought about by age, race, 
occupation, previous state of health, previous habits, 
environment, heredity, diet, recurrence of the disease, and 
a host of other modifying circumstances, that have to be 
taken into account in making up an estimate of the true 
nature and progress of this malady. 

Again, there are other features which must not be taken 
into account in the clinical study, as types, being classified 
by Lombroso as the cerebral, the gastric, the florid and 
others — some of these classes appearing rather unscientific 
for such an authority. The division, as suggested by 
some, into herpetic or erythematous, nervous or digestive, 
may be set aside as misleading, because these symptoms 
may appear, and frequently do, simultaneously. 

The elder Strambio, to whom reference has been made, 
divided pellagra into three types — the intermittent, or 
that appearing at intervals, between which the patient 




Typic pellagrous erythema of hands and wrists. (Courtesy of Dr. J. J. 
Watson, Columbia, S. C.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 79 

seemed perfectly well; the remittent, in which the dis- 
ease was better at certain seasons, though not entirely well; 
and the continuous, where no improvement took place at 
any time, but the illness progressed uninterruptedly to a 
fatal issue. 

In Italy, among the rural population, there are seven 
kinds commonly spoken of: (1) Those who go mad; (2) 
those who are drawn to water; (3) those who go backward; 
(4) those who are doubled up; (5) those who become 
giddy; (6) those who are always hungry; (7) those whose 
skin peels. 

Roussel, the most renowned French authority, has to an 
extent followed Strambio's classification, only he has made 
out a more logical case. His division is in three degrees 
primarily, and several others secondarily. 

His pellagra of the first degree corresponds to the in- 
termittent form of Strambio, only he subdivides this into 
commencing pellagra and confirmed pellagra. 

His second degree, he calls paralytic pellagra, conform- 
ing to the remittent form of Strambio. 

RousseFs third degree is denominated pellagrous cachexia, 
subdivided into that with the eruption, or a form without 
any eruption, being his idea of a pseudopellagra, or a 
cachexia dependent upon some degenerative or somatic 
stigmata. 

The division, as made by some, into commencing or 
confirmed pellagra, is certainly not a practical one clinically, 
for some, for instance, inveterate alcoholics, may be beyond 
successful treatment from the very first appearance of the 
disease; while other pellagrins assume a state of extreme 
chronicity, never becoming seriously ill with the pellagra, 



80 PELLAGRA 

and always apparently amenable for a time to favorable 
hygienic surroundings or proper medicinal treatment. 

It would appear to the writer that a classification, 
somewhat like that of Babes and Sion, is preferable, 
though even their classification cannot be followed in its 
entirety. 

They recognize a (i) prodromal stage, or pre-erythem- 
atous; (2) a stage in which there are erythema, more or 
less gastro-intestinal disturbances, and vague symptoms 
of peripheral nervous disquietude; (3) a stage of deep de- 
pression, bodily and mental, with accompanying cachexia. 

The simplest classification would naturally be the best, 
if it were possible to adopt such. The fact is patent, how- 
ever, that the evolution of pellagra from one stage to 
another cannot always be followed; that the original 
manifestations may be either cutaneous, gastro-intestinal, 
or nervous, or even pscyhic; that, while ordinarily pellagra 
is a chronic affection, there are some fulminant cases, where 
no line of demarcation can be noted from stage to stage; 
and that the cachexia may come on early or late, accord- 
ing to the patient's power of resistance. 

As emphasized by Dr. Babcock, it is well to recognize 
from the start that pellagra is a trophoneurosis. Neuras- 
thenic symptoms, though vague and nebulous, are often 
the first noticeable changes, and, when seen with the 
clearer eye of retrospection, are often as plain as the 
noonday sun. 

It should be remembered that the types vary in different 
famiHes or individuals. That it varies in races, or those 
peoples situated far apart, has already been allowed. 

In some the gastro-intestinal symptoms predominate, 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 81 

the patient having probably inherited poor digestive powers; 
in others, where an unstable nervous system, made more 
unstable, perhaps, by faulty habits, predisposes to nervous 
manifestations, such may predominate, masking every 
other feature. 

That seasonal influence may affect the skin, or that 
some cases may be apparently confined to cutaneous lesions 
alone, has been observed. 

At present the writer has under treatment a young 
girl of sixteen, who has undoubtedly the erythema of 
pellagra, and yet has never had a single qualm of any 
other bodily disturbance produced by her ailment, and 
she claims to be not the least ill. 

Sandwith does not subscribe to a " prodromal period," 
but considers pellagra to have an incubative period of 
nine to twelve months' duration, in which time there are 
undefined feelings of ill-being. 

To all intents and purposes, however, the writer thinks 
it well to admit the existence of a real prodromal period, 
during which the incipient pellagrin complains of malaise, 
languor, neuralgias, indennite pains, anorexia, occasional 
" digestive upsets," and an indescribable sense that all is 
not well. 

This may last for several years, may never develop into 
pellagra, or may merge into a typical case. One can 
never tell. 

Dr. H. F. Harris goes so far as to say that a majority of 
the people of the South to-day are suffering from one form 
or another of " corn-bread poison," as he terms it; that 
numberless cases of indigestion that eventually recover; 
that many unrecognized cachexias eventually clearing up; 



82 PELLAGRA 

that hundreds of so-called auto-intoxications are in reality 
manifestations of " corn-bread poison." 

This extreme view may not be accepted in its entirety, 
but there is more than a modicum of truth in his asser- 
tion. This he has proved in some instances by the quick 
gain in health after all corn products have been eliminated 
from the dietaries of some of these sufferers from obscure 
complaints. 

Parenthetically, in this connection, it might be well to 
caution the reader to be on the qui vive in all cases of 
atypical digestive disturbances, lest later on pellagrous 
symptoms supervene, to the chagrin of the medical attend- 
ant. 

Another source of error abides in those who have for 
long periods of time suffered with chronic indigestion, 
either functional or organic. During this long-drawn-out 
time these individuals have become so accustomed to their 
epigastric and abdominal discomforts that they ascribe 
all their ills to the " old case of indigestion," and fail to 
recognize the advent of a new factor in the pathologic 
drama. 

The writer has records of pellagrins with concurrent 
chronic gastritis of long standing, of obstinate hyperchlor- 
hydria, of gastric and duodenal ulcer, of achylia gastrica 
(quite frequent), of cholangeitis and cholecystitis, of con- 
firmed constipation with its train of accompanying tox- 
emias, and a few have been, as they say, "life-long dys- 
peptics." 

Gastric Symptoms. — The gastric symptoms of pellagra 
do not differ materially from those of chronic catarrhal 
gastritis, mostly of the hypo- or anacid variety. In gastric 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 8$ 

analyses of 64 cases of undoubted pellagra, free hydro- 
chlorid acid was absent in 18, deficient in 31, excessive in 12, 
and normal in 3. There was an excess of stomach mucus 
in 41 of these. In those who were nauseated, or suffered 
from frequent vomiting, bile was found in the stomachs 
of nearly every one. The test for occult blood was positive 
in 4. It was particularly noted that the gastric secretions 
were diminished or absent in most of the cases of long stand- 
ing, and a few, where those juices were increased, were 
rather recent cases of pellagra. 

Roussel considered the anorexia, nausea, and gastric 
indigestion as only complications, while he thought dry- 
ness of the esophagus, with dysphagia and pyrosis, the 
first true pellagrous symptoms. This fine-cut distinction 
would be hard to put in practice. 

Frequently the first train of ailments that brings up a 
suspicion of pellagra is a sensation of burning in the mouth 
and stomach, accompanied by vague neurasthenic fancies. 
Slight paresthesias and formications of small areas are 
generally also present. Upon examination, the physician 
observes a diffuse redness of the buccal mucosa, some- 
times with a few aphthous spots. This redness is not the 
bright scarlet of scarlatina, nor is it the angry hue of 
stomatitis proper, but rather a decided pink, glistening on 
the mucous membrane and imparting to the lips a cherry 
red, with a well-marked line of demarcation at the junc- 
ture of the skin. 

This buccal redness may increase, merging into vesicles 
or even superficial ulceration. Aphthous spots, about the 
mouth and on the tongue, are quite common, especially on 
the tip of the tongue and in the different sulci behind 



84 PELLAGRA 

the gums and near the fauces. Where plates of artificial 
teeth are worn, the surfaces where the plates come in con- 
tact are nearly always sore and ulcerated. 

Another point which has not been dwelt on is the tend- 
ency for the corners of the mouth to become sore. Num- 
bers of sore mouths have been treated by the writer, where, 
after all the other lesions were healed, the corners still 
remained raw and irritated. 

During this period of stomatitis and glossitis the sali- 
vary glands are quite active, even to the point of the saliva 
flowing involuntarily from the mouth. Some observers 
have claimed the saliva was acid, but, if so, it has not 
been present in any of the cases seen by the writer. Pro- 
copiu does not think this excessive secretion of saliva, 
amounting to ptyalism, is caused by the buccal irritation, 
but by the action of the toxins upon the salivary glands 
or the central nervous system. 

The appearance of the tongue in pellagra is often quite 
characteristic. It may be coated centrally, but the edges 
are smooth and slick, showing a surface denuded of epi- 
thelium. The papillae, while pronounced and some- 
times injected, show no special diagnostic points. In 
recent cases only the extreme tip and sides show this 
denuded condition, but later on the whole tongue may 
lose its epithelium, giving it a peculiarly bald look, some- 
times called the " cardinal tongue." When the redness 
is pronounced the tongue may be exquisitely sensitive 
and sore, but often a semipallor follows the loss of the 
epithelium, and a lack of feeling almost akin to anes- 
thesia supervenes. 

So often has the writer heard expressions of self-con- 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 85 

gratulation over supposed improvement of a sore tongue, 
when it was only the temporary anesthesia that would 
be followed by a greater soreness. 

This peculiar but almost constant sore tongue seems 
plain enough now, since the medical profession are on the 
lookout for pellagra, but in the years gone by gave rise 
to various and sundry diagnoses that would seem ridicu- 
lous, had they not been fraught with such possible serious 
consequences to the bewildered sufferers. 

" Superficial glossitis," " chronic glossitis," " Egyptian 
scurvy," " sprue," " tobacco tongue," and a host of other 
sobriquets settled nothing, and kept both the patient and 
physician floundering in the shallows and breakers of un- 
certainty. 

In recalling some obstinate sore mouths of former days, 
the writer is confident that a generous percentage, though 
attributed to " spoiled stomachs," to auto-intoxication, to 
chewing strong tobacco, and other causes too numerous to 
mention, were in reality the manifestations of pellagra that 
never fully materialized. 

At this early stage pellagrins often complain of shooting 
pains, almost equal to the lightning pains of tabes. Several 
instances of this sort have occurred, where incipient loco- 
motor ataxia was more than suspected, only to develop 
into pellagra later on. 

We are informed that in the European countries April 
and May are the months in which the more positive symp- 
toms make their appearance. This is true, to a marked 
extent, in America also, but May and June seem to bring 
out the pellagrous manifestations rather more than any 
other months. Dr. Babcock's opinion that September 



86 PELLAGRA 

and October are unfavorable months has not been veri- 
fied by the writer. October, instead of being a hard 
month on pellagra, often ushers in the first improvement; 
probably on account of the beginning of cool weather. 

Skin Symptoms. — The dermal manifestations will be 
next considered, though let it not be understood that they 
are necessarily the first; on the contrary, they sometimes 
do not appear until late in the course of the malady, and 
in exceptional instances accompany the closing scene. 

The first eruption begins as an erythema, not unlike a 
sunburn, and, as it generally shows on the exposed parts 
of the body, is often attributed to that agent. This 
erythema usually begins in the spring months, because, it 
is thought, the actinic rays of the sun are then specially 
strong. 

Though this skin lesion gave pellagra its name, it should 
be no more considered a purely skin disease than leprosy 
or syphilis. 

This erythema, when first noticed, consists of a redness, 
swelling, and tension of the skin, which sometimes per- 
sists only a short time, leaving the surface where it ap- 
peared scaly and rough. 

One of the most characteristic features of the eruption 
is its symmetry. A skin lesion seen on one hand or arm 
is almost sure to be duplicated on the other hand or arm; 
or one showing on one side of the face or one part of the 
body is equally seen on the corresponding side or part. 
This has become so well recognized as a diagnostic factor 
that any one of experience, who sees a " one-sided " erup- 
tion, would require much corroborative evidence of other 
kinds to make out a diagnosis of pellagra. 



' 



I 




Typic pellagrous erythema of hands. (Courtesy of Dr. J. J. "Watson, 
Columbia, S. C.) 




Showing scaling epidermis after erythema and vesication. Note absence 
of ulceration of newly formed skin. (Case from Peoria State Hospital.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 87 

Many have been the cases diagnosed as eczema — that 
dermal mantle of ignorance, covering so many diagnostic 
shortcomings. The name eczema, having a pseudoscien- 
tific sound, and being easily remembered by those whose 
dermatologic phraseology had become hazy, was generally 
applied to all sorts of skin eruptions, and little more thought 
of it until other bodily symptoms forced a more thorough 
study of the trouble. 

As Dr. Watson says, " The only type of eczema worth 
our consideration is erythematous eczema when it affects 
the hands or face. In this condition we would not have 
the tongue or digestive phenomena that occur in pellagra; 
and while these symptoms may be very mild, a history of 
their presence can be obtained if the patient is properly 
questioned. There are many points of difference between 
the erythema of pellagra and erythematous eczema, but 
the most important one is the line of demarcation between 
the erythematous area and healthy skin in pellagra, where- 
as in erythematous eczema there is no line of demarcation, 
the erythematous area merging into the healthy skin al- 
most imperceptibly. The itching in eczema is marked, 
whereas pellagrins, if complaining at all, only refer to the 
burning of the skin lesion; it never itches. Eczema has 
not the tendency to assume the light chocolate color that 
is so characteristic of pellagra. In erythematous eczema, 
as in other forms of eczema, you are very likely to find 
other eczematous lesions on the body." 

The sharp line of demarcation between inflamed and 
healthy skin is also ably described by Dr. Howard Fox in 
a recent paper. He said in part, " A characteristic feature 
of the skin lesions, fully as important as the symmetry, is 



88 PELLAGRA 

the sharply circumscribed border seen most frequently 
in the patches upon the neck and hands. Indeed, the 
lesions upon the neck, forming the so-called " neck band " 
of Casal, are absolutely distinctive, and could not well be 
confused with any other lesions of the skin. Several illus- 
trations are seen in Merk's book which are almost perfect 
counterparts of some cases seen in the South. None of 
these cases presented sternal prolongation of the neck- 
band, the so-called ' appendix fasciolea ' of Casal. Most 
of the cases were, however, in women. 

" A striking picture was also presented by the eruption 
on the backs of the hands and wrists, when the charac- 
teristic border was present. In many cases this border was 
seen not only on the back, but also upon the front of the 
wrists. In the cases in which the eruption was disappear- 
ing, the sharp border was no longer visible.' ' 

The writer is glad that Dr. Fox brought out this last 
point, for the line of demarcation being sharply cut or 
fading into obscurity often tells the difference between an 
augmenting or a declining state of pellagrous disease. 

To continue with Dr. Fox, " Comparatively few of the 
cases showed lesions upon the face. In one case there were 
lesions upon the neck and cheeks, which at first glance 
looked much like a burn that might have been produced 
by carbolic acid. Some of the cases presented lesions 
upon the dorsal surfaces of the feet. In others, the lesions 
involved the greater part of the legs and resembled an 
eczema. Few of the lesions noted upon the feet pre- 
sented a sharply marked border." 

Another skin lesion sometimes confounded with pellagra 
is erythema multiforme. To quote Dr. Watson, " Like 




Typic cervical involvement, showing well-marked " butterfly." (Case 
from Peoria State Hospital.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 89 

pellagra, the lesions are symmetric, most frequent upon 
the extensor surface of the forearms, hands, legs, and feet; 
not accompanied by marked subjective sensations. It 
differs from pellagra in that the erythematous lesions are 
markedly raised and the skin between the various lesions 
is of normal color. " 

Dr. Watson mentions six cases treated for poison oak, 
and the writer recalls several. This error could have been 
avoided by ascertaining that none of the cases had been 
where they could have encountered the poisonous plant, 
and also by remembering that the vesicles first occur be- 
tween the fingers, and extend from this point, and that 
in pellagra there are not often seen vesicles, but large bullae. 

Quite an interesting case was some time ago reported 
to the writer, in which a young man in South Georgia, 
while convalescing from pellagra, and after the erythema 
on his arm was nearly faded, came in contact with some 
poison oak, and had a sharp attack of irritation on his 
wrists and hands. The poison oak dermatitis was severe 
and painful, but it did not seem to have the least in- 
fluence on the pellagrous erythema. After the dermatitis 
had abated, the vesicles had disappeared, and all itching 
had ceased the characteristic skin lesion of pellagra was 
still in evidence, seeming to have not been affected at all. 

Another unique case was reported from Florida, where, 
during an outbreak of smallpox, a lady with a disappear- 
ing pellagrous erythema decided to be vaccinated. Her 
vaccination " took " in short order, and for several days 
she had an extremely sore arm, the inflamed area from the 
vaccination being superimposed over the original red- 
dened surface. She also had fever, general aching, and 



90 PELLAGRA 

all the uncomfortable symptoms of a vaccine infection, 
but the course of the pellagra was not modified in the least. 
Her bowels, which were inclined to diarrhea, remained 
the same, and some evidences she showed of a secondary 
pellagrous neuritis were neither mitigated nor deepened. 

Another skin lesion mentioned by Dr. Watson, as some- 
times mistaken for pellagra, is lupus erythematosus. This 
might cause some confusion, but only when the pellagrous 
erythema attacked the face, producing the characteristic 
lesion across the nose; this, however, is practically impos- 
sible without the hands being affected at the same time, 
which, of course, would at least arouse the suspicion of 
pellagra, and a search for stigmata of the disease would be 
made, and, if found, would dispel any doubt that might 
exist. 

Dr. Howard Fox, in his article entitled " Personal 
Observations on the Skin Symptoms of Pellagra," remarks, 
" The name erythema, by which the eruption of pellagra 
is generally denoted, does not appear to me to be entirely 
appropriate. It would seem quite proper to use the term 
erythema for the first stages of the disease, which resembles 
an ordinary sunburn and which lasts only a few days. But 
it seems somewhat anomalous to speak of the entire erup- 
tion as erythema, when the erythematous stage is so com- 
paratively insignificant, while the stage of desquamation 
is so characteristic and of such long duration. An erup- 
tion which is called an erythema conveys the idea of affec- 
tions such as erythema multiforme or the so-called toxic 
erythemata, which are not, as a rule, accompanied by 
desquamation. The general term dermatitis would be a 
more appropriate name, in my opinion, than erythema for 



m 




Symmetric erythema and pigmentation in pellagra. (Courtesy of Dr. 
J. W. Babcock.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 91 

the pellagrous eruption. This dermatitis particularly 
affects the back of the hands, the lower third of the fore- 
arms, occasionally also the dorsum of the feet; it also 
appears on the face, neck, and upper part of the chest; in 
fact, on the places that are uncovered and exposed to the 
sunlight. In the case of persons who, while laboring, go 
almost naked, such as the fellahs in Egypt, the greater 
part of the body is affected." 

In Roumania, where many children run naked about the 
streets, the erythema is not confined so much to the locations 
on the body mentioned, but are much more widely dissem- 
inated. Such has also been reported from Rhodesia. 

Dr. Babcock, referring to instances in Algiers, France, 
and also South Carolina, says, " Attention has been di- 
rected to a dermatitis occupying the whole vulvar region, 
as well as the perineal, the anal fold, and the internal sur- 
faces of the thighs, which are brought in contact by adduc- 
tion. Here pressure, as was noted by Sandwith, is clearly 
an exciting cause of the inflammatory eruption. In many 
of our cases the surface of the elbows and, to a less ex- 
tent, of the knees is involved for a long while. There is 
also a tendency for the dermatitis to extend from the el- 
bow down the ulnar, sometimes meeting the ' gauntlet ' 
coming up from the hand. Here, again, pressure is a 
causative factor." 

Scheube remarks, " The skin becomes red and swollen, 
causing the patient to experience a sensation of tension, 
itching, or burning. Sometimes little blebs and pustules, 
that dry up to scabs, develop. After the erythema has 
subsided for a few weeks, a desquamation of the epidermis 
in large patches takes place." 



92 PELLAGRA 

The vaginal and anal irritation has been frequently seen 
by the writer, and has constituted a most painful com- 
plication in every instance. In some of such cases the 
bowel evacuations were watery, acrid, and occasionally 
involuntary, so that the constant flow of this irritating 
fecal discharge over the inflamed surface gave rise to ex- 
cruciating agony. 

This inflammation of the mucous membrane and margins 
around the vulva and anus occasionally take on a diph- 
theritic aspect, edema may occur, followed by bullae, 
pustules, and, in rare cases, even by gangrene. Such are 
sometimes called the " wet cases." 

It is probable that some of these cases were diagnosed 
dermatitis exfoliativa in the United States some years ago. 

In pellagrins where the eruption has persisted for a 
long time it tends to assume a dingy black hue, rough and 
hard, and exceedingly disagreeable to the sufferer. These 
dark patches are more often noticed on the palms of the 
hands, the soles of the feet, on the sides of the nose, or on 
the forehead, at the junction of the eyebrows. 

When the pellagrous eruption begins to abate it first 
fades by degrees, and, if not too deep, desquamates in fine 
branny scales, leaving a bright denuded surface, eventually 
becoming normal. During this time exposure to the sun's 
rays, or even bright light, may set up a renewal of the 
erythema. 

The deeper forms of pellagrous dermatitis may exfoliate 
in large scales, leaving raw, bleeding surfaces, or even ul- 
cerated patches, requiring granulations for healing. 

The very deep inflammations of the skin, where extensive 
loss of tissue and gangrene take place, are rare, generally 




Symmetric discoloration of both forearms in pellagra. (Case of Dr. G. 

A. Zeller.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 93 

marking the terminal symptoms, and associated with 
utter failure of vital resistance. 

The skin lesions of pellagra are many and varied, but the 
writer feels that these descriptions, taken in connection with 
the illustrations of the different types, should enable the 
reader to form a satisfactory idea of their appearance. 

Digestive Symptoms. — Some of the objective findings 
of the stomach conditions have been previously touched, 
but the general digestive disturbances are of the utmost 
import and deserve careful study. 

The views of Babcock, Roussel, Procopiu, and Merk 
figure largely, correllated with the personal experience of 
the writer. 

One of the first symptoms of pellagra is an undefined 
dyspepsia, with flatulence, pyrosis, eructations, and epigas- 
tralgia. A large majority of pellagrins are dyspeptic, 
this symptom persisting to a lesser degree during remis- 
sions of the disease. This indigestion may remain in 
evidence for several years, during which time no typic 
pellagrous symptoms may appear, and this has occasioned 
Roussel's term " pellagra sine pellagra." He said, " The 
expression pellagra sine pellagra can only be applied to a 
temporary absence of the cutaneous eruption, either at the 
beginning or during the course of the malady." Strambio 
also admitted this term, though he stressed the caution that 
no positive diagnosis of pellagra should be made when 
there was no eruption, unless there was other decided 
corroborative evidence. 

The epigastralgia is a most common, sometimes perplex- 
ing, symptom, coming on at irregular intervals, and ap- 
parently bearing no relationship to the amount or kind of 



94 



PELLAGRA 



food ingested. This pain has a slight resemblance to the 
gastric crisis of locomotor ataxia, but should be easily 
differentiated if proper care is exercised. 

The intense burning of the esophagus and stomach, so 
often in evidence, is seldom due to increased hydrochloric 
acid, for that, as has been shown, is nearly always dimin- 
ished. This burning is probably analogous to the burning 
of the tongue and mouth, and to that in other parts of the 
body, to be mentioned later. 

It should not be forgotten that pellagra can be en- 
grafted on to any of the functional or organic gastric affec- 
tions, and may complicate the picture, early or late, in the 
course of the disease. 

Periods of anorexia, interspersed with happier periods 
of normal appetite, even bulimia, are among the early 
symptoms. It is not uncommon, however, for the patient 
to suffer with akoria, or the sense of increased satiety, 
where he feels a craving for food, but finds himself unable 
to eat but a few mouthfuls before feeling as if an over- 
whelming meal has been consumed. Occasionally, on 
account of the epigastralgia, the sufferer fears that differ- 
ent articles of food disagree, until there is developed a 
sitophobia, or morbid fear of food, which may lead to 
dangerous inanition unless corrected. This last-named 
symptom is usually found in cases where nervous or psychic 
symptoms predominate. 

Vomiting is seldom present, and not infrequently pa- 
tients clamor for solid food when they know full well that 
they cannot digest nor assimilate it. Records of over 200 
cases, searched with regard to vomiting, show it present 
in less than 20. 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 95 

Gastric flatulence is extremely frequent, accompanied 
by loud and explosive eructations. A few patients in the 
early stages of pellagrous indigestion have been known to 
acquire the habit of aerophagia, leading to constant and 
disconcerting eructations, which bore no relation to the 
food eaten. 

The sense of epigastric weight after meals, mainly in 
those pellagrins with previous gastric catarrhs, is often 
noted. They complain bitterly of this, sometimes walk- 
ing partly doubled up in the hope of temporary relief . 

The few cases of duodenal ulcer complicating pellagra 
have shown all the clinical symptoms of that entity plus 
those of the pellagra. The same may be said concerning 
the cases of peptic ulcer. 

Flatulence is also frequently observed in the small 
intestine, occasioning abdominal discomfort, borborygmi, 
and colicky pains. Very often increased peristalsis is set 
up soon after each meal. 

In one instance the writer had the opportunity of ex- 
amining the duodenal contents of a pellagrin. The con- 
tents were obtained by the Einhorn duodenal bucket, 
which was withdrawn ten hours after swallowing. The 
contents were a golden yellow, thick and turbid, and 
showing no reaction for trypsin. This, of course, proves 
nothing, being mentioned only as a matter of interest. 

Occasionally constipation is found in the earlier stages 
of pellagra, but this is exceptional. The few instances 
coming under the writer's notice were chronically con- 
stipated long before the advent of the pellagra. A case 
-of pellagra, where constipation persists, may be classed 
as a decided rarity. 



96 PELLAGRA 

The usual rule is to get a history of attacks of diarrhea, 
apparently causeless, not depending on what is eaten, and 
ceasing suddenly. This diarrhea is believed by Babes to be 
due to irritation of the sympathetic ganglia and the plexus 
of Auerbach. This view has only recently been accepted 
by American observers, for two years ago, when the writer 
contended that the first diarrheal manifestations were of 
central origin and compensatory in character, his views were 
acquiesced in by only a few students of pellagra. 

Strambio distinguished two kinds of diarrhea, the one 
a dysentery characterized by frequent colicky and muco- 
sanguinolent stools; the other more common, and character- 
ized by watery discharges, frequent, and hard to control. 
According to him the dysenteric is more common in the 
earlier stage, but the serous or aqueous diarrhea belongs 
to the later and progressive stage, and is an important 
factor in producing the cachexia. 

According to the experience and observation of the 
writer, this early diarrhea is often very watery, explosively 
ejected, and hard for the patient to control. This tendency 
to lose control of the anal sphincters soon after the advent 
of the first diarrhea has, so far as observed, been particu- 
larly noticed. 

A recent case of this sort was a young widow, whose 
greatest complaint was her lack of control of her bowels, 
causing frequent soiling of her linen. At present she is 
better in many ways, but still reports difficulty in manag- 
ing her sphincters. 

The odor of these pellagrous stools is almost character- 
istic. To describe an odor is at the best unsatisfactory, 
but, like that exhaled from smallpox patients in the des- 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 97 

quamative stage, or the peculiar smell of the vaginal 
discharges in uterine carcinoma, these feces have a dis- 
tinctive odor. The feces are usually dark, often very 
watery, irritating to the parts over which they pass, and 
full of frothy bubbles of gas. 

Several who have seen many cases of pellagra, and had 
occasion to often smell these foul stools, have expressed 
the belief that they could diagnose pellagra fairly well 
from the olfactory senses alone. In this somewhat bizarre 
statement the writer is tempted to concur. 

The diarrhea, of central origin and compensatory at first, 
becomes eventually inflammatory in nature, partaking of 
all the symptoms of irritative diarrhea or ordinary dysen- 
tery. When this condition arrives, it is no longer com- 
pensatory or salutory in its effect, but rapidly saps the 
strength and reduces the weight. It is not uncommon to 
see a patient lose five to ten pounds in a week from such a 
cause. The diarrhea may even become choleraic, draining 
the body of its fluid in short order. 

Should the disease progress favorably, and the patient 
seem convalescent, the whole digestive system remains 
below par for long after. The appetite is finical, the 
stomach easily upset, flatulence often in evidence; while 
the slightest indiscretion in either eating or otherwise is 
sure to result in a renewal of the diarrhea. 

Can it be wondered that so many healed pellagrins be- 
come confirmed " nervous dyspeptics, " afraid to eat a 
sufficiency for daily calories, and at all times sitophobic 
to a degree? 

Before leaving the alimentary tract it might be well to 
mention that when patients complain of hemorrhoids, as 



98 PELLAGRA 

they frequently do, an investigation will reveal a proc- 
titis, which will explain some of their " bearing-down " 
pains, and whose relief will greatly ameliorate the general 
condition. 

It is the opinion of many that the digestive symptoms of 
pellagra in the United States run a more severe course 
than in Europe, especially in Italy. An idea prevailing 
in some quarters is that in those countries there has been 
acquired, either through heredity or some other manner, a 
gradual immunity, which has rendered the pellagrous 
toxin less able to make the rapid inroads observed in a 
newer soil for its invasion. 

So much for the gastro-intestinal disorders of pellagra. 

Nervous Phenomena. — Before entering into the psychic 
manifestations of this malady the more strictly nervous 
symptoms will be considered, though it will be impossible 
to keep the nervous and psychic separate at all times. 

As has been admitted, many of the expressions are those 
of a trophoneurosis, and can be explained in no other way. 
The many pains, the burning surfaces, the quick and sur- 
prising changes in the aspect of pellagra from day to day, 
are necessarily the result of certain neuroses, some of them 
understood, some still obscure. 

From the first fleeting pains, accompanied often by 
paresthesias and formication, to the flickering pangs of a 
disappearing neuritis, the last sign of the disease, nervous 
symptoms are in evidence practically the entire time. 

One of the very first indications is a dysphagia, coming 
on intermittently and disappearing without reason. The 
patient naturally cannot understand such a phenomenon, 
comes to the physician for advice, and is surprised to find 




This case shows a marked and extensive dermatitis over back and front 
of neck, face, forearms, hands, legs, and feet. Was transfused from sister, 
who had never had pellagra. Marked improvement for eight days. Died 
suddenly at night from perforation of intestinal ulcer. (Courtesy of Dr. 
H. P. Cole, Mobile, Ala.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 99 

that the dysphagia has disappeared. It is then thought 
to be an hysteric manifestation, until other indications of 
pellagra are felt. 

Early tremors are not rare, appearing somewhat like 
the tremors of disseminated sclerosis. These tremors are 
more marked in the hands than elsewhere, though the 
tongue is often affected. Frequently the patient is unable 
to stand with the eyes closed, swaying almost as much as 
in tabes. 

An instance of this sort was under the care of the writer 
several months ago. The patient, a young lady of good 
circumstances and breeding, first noted the tremors on 
attempting to pass food on the table to other members of 
the family. These tremors in a short while began to affect 
her tongue, making her speech halting and uncertain. 
She found that she walked in the dark with difficulty and 
was timorous about walking alone. Her family physician, 
a gentleman of intelligence, thought it a beginning neuras- 
thenia brought on by a period of religious excitement ex- 
perienced at a series of services, which were led by an 
evangelist of the superstrenuous sort. 

Soon after, she noted an intermittent diarrhea and in- 
digestion, and in a few months the erythema confirmed the 
diagnosis already suspected. After a serious illness, in 
which nervous and psychic symptoms predominated, im- 
provement set in, and she seems convalescent at this time. 

Contractures are generally late symptoms and of grave 
prognostic import. The writer has not observed many, 
but others have met with contractures quite often in vary- 
ing degrees of severity. These patients move with diffi- 
culty, are averse to any change of position, and sometimes, 



ioo PELLAGRA 

in their efforts to find a comfortable pose, assume grotesque 
attitudes that would provoke laughter were the patient's 
condition not one of such misery. 
A most remarkable case of this sort is narrated by Marie : 
" In the case of one woman the skin was cadaverous and 
covered with telangiectases, the chestnut-brown hair scat- 
tered over with white and reddish spots, a rude beard, 
cranium ultrabrachycephalic, nose flat, teeth of the upper 
jaw worn away by constant friction, and, from this cause 
doubtless, a varicose nodule had formed on the tip of the 
tongue; emotional reaction was feeble, but not abolished; 
tactile and painful sensibility was much diminished; she 
was resistant; mentally she presented the picture of de- 
mentia precox of the depressed type and was mute; hid 
herself in fear in the most retired corners of the room or 
yard; if any one succeeded in making her talk, she did not 
seem to be deluded, but begged others about her to have pity 
on her misery, and was grateful for attentions received, of 
which she thought herself unworthy. All her inclinations 
and all her psychic activity expressed themselves in the 
most extreme muscular contractions. She sought the 
most favorable positions for contortions while hanging 
to slats and bars, to which she clung even with her teeth, 
her tongue, and toes. She gave as an explanation that 
she could not do otherwise. These symptoms continued 
up to her death, from tuberculosis, although in the last few 
days she uttered monosyllables — ' good, bad, your kind- 
ness, so much misery/ etc. But up to the last day she 
continued to conceal herself as much as possible under 
the cover, and to cling with her feet to the bars of the bed." 
We are informed by Italian writers that in some in- 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 101 

stances laborers seem to feel a greater strength than usual 
when first attacked by pellagra. Such has not been ob- 
served in this country, but, on the contrary, weakness and 
uncertainty of the lower limbs are frequently noted among 
the first symptoms. There may be even pareses, though 
Tonnini, a contemporaneous Italian observer, claims that 
pellagrous paresis never attacks the muscles of respiration 
or those of the face alone. 

Among other neuroses are muscular spasms, tetanic 
convulsions, epileptiform seizures, and sudden attacks of 
vertigo. Some of these muscular spasms produce very 
erratic movements, giving rise to some of the queer classi- 
fications bestowed upon the disease by uneducated people. 
These sufferers, during such attacks, fall backward or 
sidewise, or jerk in choreic fashion. These attacks are 
precipitated or made worse by external sensory impres- 
sions, such as loud talking, slamming of doors, etc. 

Practically all pellagrins possess exaggerated reflexes, the 
normal or diminished reflexes being in a decided minority. 
Sometimes, though not often, there is a difference in the 
two sides, or ankle clonus is wanting. 

The skin reflexes are generally either increased or de- 
creased, seldom normal. When increased, the mechan- 
ical irritability of the muscles is in most cases also in- 
creased. 

The electric reactions of the muscles and nerves have 
been studied by Roncoroni in the hospital of Turin. These 
experiments were made on four pellagrins, three of whom 
were in good physical condition. They did not display 
the reaction of degeneration and did not show any devia- 
tion, either quantitative or qualitative, from the normal. 



102 PELLAGRA 

In one case excitability was notably less than in the others, 
which was probably due to profound denutrition. This 
is not without interest for differential diagnosis from 
polyneuritis, progressive muscular atrophy, lateral amyo- 
trophic sclerosis, transverse myelitis, and other diseases. 
He also found a greater faradic excitability of the flexors. 
According to him, diminution of the faradic excitability, 
even in the cases of spastic rigidity, is found in the third 
period of pellagra; under certain circumstances this reac- 
tion might serve as a differential diagnostic sign from 
spastic spinal paralysis. 

In the majority of pellagrins, however, unless there are 
marked nervous symptoms, the ordinary gait is not mate- 
rially changed. 

Warnock says, " There is no special gait in early cases, 
but when the disease has become advanced the patient 
walks with the legs well apart, the shoulders raised and 
bent forward, and when he has reached the penultimate 
stage he cannot take more than a few short feeble steps 
without falling down, while in the last stage of all the 
patients are unable |to stand up or even raise themselves 
up in bed, and this paresis is sometimes accompanied by 
tremors of the limbs.' ' 

In the last stages, of course, the reflexes are all abol- 
ished. 

The sensibility to touch and pain is in most cases of 
pellagra diminished, with the frequent exception of the area 
over the epigastrium and abdomen. " Out of 30 severe 
cases, Tonnini found five times a profound analgesia ex- 
tending from the feet even to the face, but greater in the 
lower extremities; he found more or less analgesia fourteen 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 103 

times and hyperalgesia four times. In 40 pellagrins less 
severely affected he found two-thirds analgesic and only 
two hyperalgesic." 

" Hyperalgesia in pellagra is more common in florid types, 
and is accompanied by a decided elevation of temperature. 
The cases are numerous in which if they are touched, prin- 
cipally on the stomach or on the thorax, they begin to cry 
out, and at the least noise they start; others have painful 
paresthesias, as if water were thrown on their heads, or as 
if they were pricked on the legs by thousands of pins; 
they complain also of burning in the eyes, in the nose, and 
in the face. Insensibility to pain is often shown by their 
voluntary exposure to cold, as well as to burning or scorch- 
ing, to which they repeatedly expose themselves. Tonnini 
found the sensibility to heat better preserved in the face than 
in the extremities, but sometimes cryesthesia is found. " 

These abnormal sensations of the skin and other parts of 
the anatomy, these aching pains and burning sensations, 
have been the bane of many of the pellagrins under the 
observation of the writer. In a number of instances, after 
seeing the patients safely through the gastro-intestinal dis- 
turbance, the eruption and the weakness, the manifesta- 
tions of neuritis were so severe and obstinate that they have 
broken away, going from one medical advisor to another 
in frantic efforts to obtain relief. These are the invalids 
who readily become a prey to charlatans and quacks and 
all that ilk, who, by specious and misleading representa- 
tions, extort " blood money " from these poor desperate 
sufferers. 

The daily papers have recently carried advertisements of 
a vaunted " pellagra cure," where a tiny bottle was sold for 



104 PELLAGRA 

an unreasonable price, and where a guarantee to cure was 
included. To bolster up these ridiculous claims were 
printed letters from supposed pellagrins, claiming to be 
cured in from ten to fifteen days — God save the mark! 

Cephalalgia of the severest sort is not uncommon. With 
the headache is ringing in the ears and dizziness. Dr. 
L. C. Allen mentions a patient of his, a fine old gentleman, 
who would often say, "I'm drunk, doctor, I'm drunk; 
I have not drank anything, but I'm drunk." He would 
often fall down and bruise his head. He died soon after. 

With the exception of an occasional explosion of erotic 
passion during the incipiency, the sexual desire is either 
diminished or abolished in pellagra. This the writer has 
noted quite a number of times, and it does not seem to 
be mentioned specially in contemporary literature. In one 
instance, a middle-aged man consulted a specialist in 
Atlanta for impotence, not considering the concurrent 
symptoms of indigestion and diarrhea of importance. 
This physician became suspicious, and, on having the case 
thoroughly investigated, was able to inform the patient 
that the trouble was incipient pellagra. 

The olfactories are not obtunded in this disease, but, 
as in some gastric disorders, often seem to be more acute. 
A young woman at the Tabernacle Infirmary in Atlanta 
informed the writer that she could detect and differentiate 
odors since her illness that would have been beyond her 
power during health. These patients, with squeamish 
stomachs at best, cannot eat or drink when their olfactories 
are offended, and this heightened sense is quite a problem 
to manage at times. The sense of smell is, in serious cases, 
about the last one to be lost. 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 105 

The sense of taste must be judged by different stand- 
ards. It is certain that bitter or very sweet articles can 
be distinguished, but all discriminating taste is soon lost 
in the presence of the sore tongue and mouth. 

Another anomaly of sensation, and one of the most 
annoying, is the pruritus in the groins, or in the back and 
arms. Sometimes, in females, where the vulvovaginal 
margin is inflamed, this itching is so exasperating as to 
almost drive them to suicide. In a middle-aged lady, 
seen in the northern part of this state some time ago, this 
vulval and vaginal pruritus caused her more suffering than 
all her other symptoms. 

The line of demarcation between the nervous and 
psychic manifestations is dimly drawn, and one merges 
into the other at nearly every point. The psychology of 
pellagra has not been studied long enough in the United 
States for much authoritative literature to have been 
accumulated. We are, to a large extent, dependent upon 
our studious friends in Italy and France for data in these 
protean manifestations of pellagra. 

Some time ago the writer attempted to make some 
groupings of the psychic symptoms, but with nearly every 
new case a new viewpoint was brought to view, leaving 
the question more mixed and murky than before. With 
many misgivings, therefore, the difficult task will be 
undertaken. 

Many pellagrins are quite sane, and always remain so, 
but there are few but who will admit a sense of mental 
depression, a feeling of misgiving, a vague unrest, or pre- 
monitions of impending disaster at some period of their 
illness. 



106 PELLAGRA 

The facial expression of pellagra, after two or three 
recurrences, is indicative of trouble and care. The deep- 
ened furrows attest the prolonged worry, and the oblique 
puckering of the eyebrows increases the grief-worn ex- 
pression. The fades in pellagra is worth attention. 

Insomnia comes on early and persists until convales- 
cence is well under way. Very few pellagrins are good 
sleepers while the disease is making progress. 

Among the first psychic symptoms are temperamental 
differences, perhaps not realized by the patient. Unreason- 
ing discontent at petty discomforts and unreasoning anger 
at slight annoyances are not uncommon. 

Two years ago a gentleman from a neighboring state 
was under treatment, whose first symptoms were a dislike 
for his two little children, of whom he had previously been 
very fond. Their childish prattle exasperated him, and 
he admitted that he could not understand why. These 
peculiar feelings of antipathy for his children lasted six or 
more months before any other manifestations of a pella- 
grous nature became patent. He then began to suffer 
from indigestion, loss of weight, and diarrhea, and in a short 
while the tell-tale erythema of the hands furnished the last 
necessary link in the diagnosis. 

Next the patient finds that thinking or calculating is an 
effort; he becomes irritable or excitable when in the com- 
pany of others, or morose and despondent when alone. 

In the intermittent type there is seldom any decided 
symptoms before the second recrudescence, but after that 
a settled gloom begins to fall over his spirits. He is sad, 
uninterested in what is going on about him, but conten- 
tious for his own rights. His sleeplessness is troublesome, 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 107 

his surroundings are distasteful, and he evinces a desire 
to wander away. Sometimes a sense of having committed 
a dreadful crime comes over the mentality, and fears of 
detection and punishment are added to the burden, heavy 
enough before. Obsessions of having injured loved ones, 
of having been guilty of some loathsome transgressions 
against the laws of God or man, tills the sick soul with 
grievous remorse. 

Sometimes, with the burning and itching sensations, 
comes the delusions of being burnt. There are also fre- 
quent delusions of persecution. With negroes the thought 
of being bewitched is uppermost in their minds, and they 
seek strange charms and curious objects, which they think 
have the power to drive away the evil and torturing 
spirits. These poor creatures are easily frightened, easily 
panic-stricken. They seek escape in flight, and hallucina- 
tions of poison often make them refuse food and drink to 
the point of inanition. 

As in some other delusional insanities, they are prone 
to feel the greatest antipathy for and fear of their dearest 
relatives and friends, attributing sinister motives to all 
attempted acts of kindness. 

As the descent into Avernus is swift, so the mental de- 
cline is rapidly progressive, deepening from discontent to 
sadness, sadness to melancholy, melancholy to confirmed 
melancholia, and on down the psychic decline to dementia. 
The writer is informed by one alienist that about half the 
pellagrins who applied to him were already melancholic, 
though not at the time insane. 

Dr. Holland, in describing these symptoms, said, "The 
pellagrosi complain of a sense of heat in the head and 



108 PELLAGRA 

spinal cord, of tingling and darting pains in the course 
of the nervous system, of heat in the limbs, palms of the 
hands, and particularly in the soles of the feet; of great 
weakness of the limbs, with trembling when attempting 
to stand, and sometimes of contractions of the lower limbs. 
Their looks become somber and melancholy. Ennui, de- 
pression of spirits, and mental imbecility increase with 
the progress of the malady." He also states the pella- 
grosi afford a melancholy spectacle of physical and moral 
suffering at this period. They seem under the influence of 
an invincible despondency, they seek to be alone, scarcely 
answering questions to them, and often shed tears without 
obvious cause. Their faculties and senses are impaired, 
and the disease, when it does not carry them off from ex- 
haustion of the vital powers, generally leaves them insen- 
sible idiots, or produces attacks of mania, soon passing 
into utter imbecility or idiocy. 

The following case, as reported by Sandwith, shows 
several sides of pellagra manifested in one patient, but par- 
ticularly the psychic aspect, " M. H., an Egyptian peanut 
woman, aged thirty, was admitted to Kasr Ainy on April 
17, 1897. She had a well-marked pellagrous eruption, 
was thin and weak, and abnormally hungry. She passed 
her excreta in bed or anywhere in the ward, and had to 
be prevented from eating dirt. She was melancholic, 
unwilling to talk, and when spoken to she repeated the 
question and seemed unable to reply. At night she would 
get out of her bed and walk about the passages. She 
had favus all over her scalp, and ankylostomiasis, which 
required four doses of thymol. We afterward found 
from her relations that one morning she had gone down 






(• 




I 

Well-marked manifestations of pellagra. (Courtesy of Dr. Beverly 
Tucker, Richmond, Va.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 109 

to the river to bathe, and had then wandered some miles 
along the river bank until she reached Cairo. On Oc- 
tober 9th she was discharged from the hospital, having 
increased in weight thirty- two pounds; she now smiles, 
talks, helps the other patients in the ward, understands all 
that is said to her, and seems quite sensible; she has no 
eruption, and her tongue is quite normal. Her knee-jerks 
are still too brisk, and she still weeps rather easily if she 
has any disagreements with the other patients." 

The writer, not being an expert alienist, feels disposed to 
defer to those who have more thoroughly tilled the psychic 
field, and have garnered a more seasoned burden of scien- 
tific ideas. As such, Dr. J. W. Babcock stands in the 
forefront, and the remaining discussion concerning the 
psychology of pellagra is extracted from his recent paper, 
" The Psychology of Pellagra," being made up of his own 
views and the views of others, as collated by him. Hack 
Tuke studied pellagra in Italian asylums in 1865. He 
says, " The patients were in advanced stages of the disease, 
and were all more or less emaciated, sallow, anemic, and 
presenting a miserable dry, wrinkled skin. They were 
obtuse and inert, their mental state being that of dementia, 
quiet, chronic mania; or T in some instances, chronic melan- 
cholia. None of them was in an acute maniacal condi- 
tion." 

The views of Salerio, director of the asylum of San 
Servolo, Venice, upon the mental condition of his patients, 
may thus be summarized, " They are generally frightened; 
think they are pursued or possessed of a devil, suspicious, 
refuse food and medicine, and have exalted religious notions. 
Suicidal tendencies may be present. Homesickness is 



Iio PELLAGRA 

common and severe. Finally, they are liable to lapse into 
dementia, paralysis, or tubercular diseases.' ' 

Bucknill and Tuke quote also from an early work of 
Lombroso, who thought that one characteristic of pella- 
grins, sane or insane, was the greater moral impression- 
ability. A slight insult, the threatening of some trivial 
danger, completely carries them away. If pellagrous 
insanity assumes a type, it approaches rather that of 
chronic mania and dementia than that of monomania. 
This Lombroso ingeniously terms " psychical catalepsy." 
But, as a rule, their sanity is of a misty, ill-defined, con- 
tradictory character, like that produced by old age or by 
anemia, and differing on this point from general paralysis. 

Morselli gives four forms of pellagrous insanity, viz., 
supra-acute pellagra (typhoid pellagra), pellagrous melan- 
cholia, pellagrous dementia, and pellagrous pseudogeneral 
paralysis. 

Babes and Sion say, in part, " Usually after several 
years of somatic pellagra, psychic symptoms come into 
prominence. At first the patients experience mental 
weakness. The peculiar pellagrous lunacy is preceeded 
by spasmodic, then tonic, cramps and general bodily weak- 
ness, and advanced to true pellagrous paralysis. The 
cramps of feet, hands, and calf muscles are sometimes 
so violent that they may result in epilepsy, contractions, 
and swooning. So-called pellagrous epilepsy occurs as 
the result of spinal pain, the patient being drawn back- 
ward. An important condition, called pellagrous tetanus, 
has been described by Strambio, opisthotonos being a 
common characteristic symptom. Sometimes the pa- 
tients are drawn forward and fall to the ground. Chorei- 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA in 

form movements, especially of the head, are observed, 
generally from the incipiency of the disease; depression 
and weakness of the memory are noted. Roussel asserts 
that in this stage deliria do not appear, but that they come 
on in the spring of the second or third year. The sadness 
may advance to mutism and refusal of food; these condi- 
tions often being interrupted by lachrymose or maniacal 
or suicidal episodes. An acute attack leaves the patient 
exhausted, depressed, and hypochondriac. Such attacks 
recur annually at about the same time, the intellect 
weakens, and gradually dementia develops. 

"Pellagrous melancholia shows various stages: at first, 
there are psychic impediments, followed by apathy or 
stupor. Delusions of sin, of persecution, etc., appear. 
Mania is rare, but catalepsy sometimes occurs. 

" When paralysis supervenes, euphoria appears, pre- 
senting a disease-complex like general paralysis, but even 
in advanced stages of the disease remissions may occur." 

G. Antonini writes, " Already, in the first stages of 
pellagra, there appears a decided modification in the 
mental faculties; there is a great impressionability, a 
greater psychic excitability; a slight disappointment 
depresses greatly the tone of feelings or produces ex- 
cessive reactions (from the want of initial inhibitory 
powers). In the progress of the disease we can have true 
amentia, states of mental confusion common to all psy- 
choses arising from exhaustion. This state can show sud- 
denly an- aggravation of symptoms and lead to death with 
a syndrome of acute deHrium (typhoid pellagra), and yet 
it can also present in certain cases a true progressive 
paralysis of pellagra. 



112 PELLAGRA 

" But a frequent symptom is the obstinate refusal to 
take food, such as aggravates painfully the already sad 
picture of the pellagrin. ,, 

Griesinger notes that pellagrous insanity, according to 
Clerici (1855), consists chiefly in a vague, incoherent 
delirium, accompanied by stupor, loss of memory, and 
by loquacity without special disorder of intelligence or 
violent excitement; the melancholic state, which pre- 
dominates for a long time, always passes gradually into a 
state of torpor of all the mental powers, with muscular 
weakness, which greatly resembles general paralysis. 

Mongeri concludes that the pellagrous psychoses begin, 
ordinarily, with a period of mental depression accom- 
panied by hypochondriac ideas. Following great mental 
prostration the ideas become confused. Later melan- 
cholia appears, accompanied by hallucinations of hearing, 
with illusions of general sensibility. Following this con- 
dition are delusions of persecution with a tendency to 
drowning (the hydromania of Strambio). Again, develop- 
ing persecutory paranoia, pellagrins commit crimes of every 
sort (homicide, infanticide, incendiarism, etc.). Dementia 
is the common termination. 

According to Bianchi, one of the leading modern Italian 
writers, " The nervous phenomena dominate the scene in 
pellagra. We may classify the different varieties in two 
groups, the chronic and the acute. The first is charac- 
terized by general depression, melancholia, confusion, 
slow dementia, paresthesias, and ataxic gait. Contrac- 
tures and subsulti are absent, although in most instances 
the reflexes are exaggerated. In the acute form we have 
elevation of temperature (39 ° to 41 ° C), intense neuro- 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 113 

muscular excitement, subsulti, contractures, muscular 
rigidity, exaggerated reflexes, and confusion with phases 
of exaltation. There are numerous intermediate forms in 
which we observe a great variety of psychic phenomena, 
and also alternation of excitement and depression. Phases 
of remission and of apparent recovery are observed, espe- 
cially at certain seasons.' ' 

Regis announces that, "It is recognized that the most 
common form of psychosis in pellagra is mental confusion, 
with melancholy or dreamy delirium. This occurs more 
or less marked in most of the cases. It is manifested by 
an inertia, a passivity, an indifference, a considerable tor- 
por; by insomnia, hallucinations often terrifying, both of 
sight and hearing; by delirious conceptions, with fixed 
ideas of hopelessness, of damnation, of fear, persecution, 
poisoning, anxiety, of possession of devils and witches, of 
refusal of food, and so marked a tendency to suicide and 
to suicide by drowning that Strambio gave it the name 
hydromania. This melancholy depression, which can 
reach, in certain cases, even to stupor, is always based 
upon a foundation of obtusion, of intellectual hebetude, 
and of considerable general debility, which becomes per- 
manent and terminates by degrees in dementia, in pro- 
portion as the pellagrous cachexia makes new progress. 
It is accompanied sometimes by a polyneuritis. The 
mental confusion of pellagrins can, in place of changing 
directly into dementia, turn to a chronic mental confusion. 

" One may also observe in pellagra, as in every chronic 
grave intoxication, a morbid state resembling general 
paralysis (pellagrous pseudogeneral paralysis). This oc- 
curs especially in the cases where, instead of habitual 



114 PELLAGRA 

melancholy ideas, the patients present ideas of satisfac- 
tion and of wealth." 

Procopiu discusses the subject at length, saying in part, 
" We have seen that the character and intelligence of pella- 
grins change. They become sad, apathetic, silent; in the 
more advanced stage they are melancholy, and fall some- 
times into an absolute mutism or respond with difficulty, 
and have the air of not understanding what is said to them. 

" Sometimes this melancholy is accompanied with 
stupor, and leads the poor pellagrins into dementia. 

" It is not rare in this condition that an attack of acute 
mania breaks out. At another time the attack of mania 
breaks forth suddenly without apparent cause, or under 
the influence of a sunstroke, a quarrel, a disappointment, 
etc. 

" Sometimes it is in the spring that the excitement, as 
the other symptoms of pellagra, makes its appearance, but 
generally it is later than the others, and bursts forth at 
the end of the season or even during the summer. 

" Pellagrous insanity has been divided into acute and 
chronic forms. The acute form is more frequent when 
the pellagra is associated with alcoholism; then this form 
presents the characters of delirium tremens. The acute 
form often manifests itself in the course of the chronic form, 
but it can also begin in the state of apparent health. 

" The acute insanity, in particular, which bursts out 
suddenly while the patient is in a state of mental health, 
is easy enough to cure. But when the disease is advanced, 
and the lesions of the nerve-centers are profound, cure is 
difficult, sometimes impossible, especially in the case of 
dementia. When even a sensible amelioration is obtained, 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 115 

the intellectual condition of the patients remains always 
in a marked degree of inferiority. " 

From the more recent treatise of Tanzi, we learn that 
" pellagra is almost always accompanied by psychic dis- 
turbances, which often have the character of true mental 
diseases. 

" A pellagrous melancholia and a pellagrous mania have 
been described. The characteristic psychosis of pellagra 
is, however, amentia, which manifests itself acutely in loss 
of sense of place, loss of memory, confusion, hallucinations, 
and paresthesias, from which there arise morbid impulses 
and delusions. Pellagrous amentia often assumes a 
depressive form which simulates melancholia, and in some 
cases, either from time to time or throughout the whole 
course of the psychosis, it is accompanied by exaltation, 
which gives it some resemblance to mania. 

" The first atack of amentia occurs after pellagra has 
existed for some years and has already given rise to ery- 
thema and diarrhea, and has remitted from time to time. 
In other words, the pellagrous lunatic is, as a rule, a 
chronic sufferer from pellagra. But while the pellagra, 
although chronic, continues to run an intermittent course, 
the mental disturbances associated with it have the char- 
acteristics of an acute insanity, which corresponds exactly 
to amentia, i. e., to the most typic of the acute insanities, 
both as regards the symptoms and course. 

" The insanity of pellagra is thus something different 
from common melancholia or from ordinary mania. It is 
also something more than simple amentia. We may re- 
gard it as the combination of two distinct clinical pictures; 
namely, that of amentia in the first attacks, and that of 



Il6 PELLAGRA 

dementia in the later and progressive phase, marked by- 
chronic and incurable cachexia. It is an intermittent 
and progressive amentia, which, if not cured, or if not early- 
fatal, terminates in dementia.' ' 

Babcock here inquires what is the relationship of pellagra 
to progressive paralysis? 

" Baillarger asserts that pellagra may be followed not 
only by mania and melancholia, but also by progressive 
paralysis. Verga opposes the last opinion, while Regis and 
Piannetta affirm it." 

Gregor, in 1907, recognizing that exhaustive clinical 
observations on the so-called mental disturbances of 
pellagra were wanting, made careful analysis of the psychic 
condition observed in 72 cases who had been admitted to 
the Bukowina State Asylum from March, 1904, to Sep- 
tember, 1905. In 1902, he says, Finzi published his 
" Psicose Pellagrose," coming to the conclusion that this 
mental disturbance is essentially an insanity, and that 
the psychosis of pellagra is amentia. This view, which 
agrees with that of Tanzi, was combated by Vedrani, who 
maintains that the psychosis of pellagra takes usually its 
course without serious disturbances of orientation and 
reason. On the other hand, Warnock claims that symp- 
toms of melancholia are the usual accompaniments of the 
mental disturbances in pellagra, and thus approaches the 
views of the older writers, who assumed especially close 
relations between pellagra and melacholia. Thus Aubert 
tried to prove, in 1858, that an attack of pellagra might 
convert a heterogeneous disease into melancholia. This 
view was vigorously maintained by Aubert against Bail- 
larger and others, who held that the psychoses of pellagra 




Well-marked vesication of temporal and mastoid regions, known as the 
" butterfly." (Case of Dr. G. A. Zeller.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 117 

are polymorphic, including meningitis, mania, melancholia, 
etc., and even general paralysis. This view is still main- 
tained, notably by Zletarovic, who has observed the de- 
velopment on the basis of nutritive disturbance caused by 
pellagra of melancholia and mental weakness to complete 
stupor and dementia, but he never observed mania. Even 
Lombroso and Tuczek, says Gregor, give only pictures of 
psychic conditions. Gregor also considers the studies of 
pellagrous insanity by Finzi and Vedrani as inadequate, 
but, granting the absence of a characteristic symptom- 
complex, he says that we must still search for characteristic 
peculiarities, since psychoses, which are in themselves not 
specific, may assume certain symptoms which are to be 
considered with regard to their etiology. 

Gregor also included in his study whether the relation- 
ship between pellagra and the psychoses was accidental or 
casual. It will thus appear that he attempts to reach a 
much broader and deeper conception of the neuroses and 
psychoses of pellagra. He divided his 72 cases into seven 
groups: (1) Neurasthenia, (2) acute stuporous dementia, 
(3) amentia (acute confusional insanity), (4) delirium 
acutum, (5) katatonia, (6) anxiety psychoses, and (7) 
maniac-depressive insanity. 

In the following summary Dr. Babcock gives Gregor's 
analyses : 

" Neurasthenia. — The symptoms of Gregor's first group 
in their details are not specific of pellagra, but offer in their 
totality a characteristic disease-picture. 

" The symptoms are subjective, and include headache, 
pain in the gastric region, vertigo, paresthesias, lassitude, 
depression, a sense of unrest and anxiety, which may be 



n8 PELLAGRA 

raised to a phobia, as well as ill-defined apprehensions. 
There is also a sense of bodily and mental incapacity and of 
illness. Their conduct is normal, and the intellect may be 
unimpaired, but they are incapable of mental and physical 
exertion. The process of association is distinctly dis- 
turbed, the simplest question often being answered only 
after prolonged hesitation. With depression of spirits, 
hypochondriac notions may develop from a consciousness 
of being pellagrous, or experience in former illnesses. 
In some cases there is a slight motor unrest and a desire 
to move about, but, as a rule, patients of this group labor 
under motor impediment, and sink finally into a condition 
of apathy and resigned inactivity. Gregor admits that 
these symptoms are not specific of pellagra, but he sug- 
gests that, if these symptoms have lasted for several years, 
the suspicion of pellagra as a causative factor should be 
aroused in the physician's mind, even without the presence 
of the somatic stigmata of the disease. He also observed 
that the first attack of pellagra is more likely to be accom- 
panied by neurasthenia, and that this condition commonly 
preceded the development of the pellagrous psychoses. 

" Acute {Stuporous) Dementia. — The milder cases of 
this group differ from the preceding group only in degree. 
The symptoms, merely suggested in the former group, 
exist here in full force. The cases of this group are char- 
acterized by a distinctly marked stupor, tending to remis- 
sions, by deep mental depression, a vivid sense of insuffi- 
ciency, and peculiar subjective troubles. The dependence 
upon pellagra intoxication can be established by the 
close connection of the psychic disease-picture with the 
somatic symptoms of pellagra. The mental symptoms 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 119 

improve with the bodily. The external appearances, the 
depressed mental condition, the tendency to suicide, etc., 
explain the fact that such cases are frequently considered 
melancholia. Finzi contradicts this view, and places 
these cases under amentia. Some of Tanzi's and Vedrani's 
cases come under this group. 

" The patients give the impression of being sick, as they 
he still and apathetic in bed for weeks, and answer repeated 
questions only after a painful effort, or not at all. Re- 
quests of the simplest nature are carried out only with hesi- 
tation and effort, and often the action once begun is inter- 
rupted in its first phase, or the request is forgotten. Mostly 
we are assured that the patients are well oriented, and 
often we see, after the hesitation ceases, that the psychic 
activity is revived for a short while, but, sometimes in 
the height of the disease orientation may be disturbed. 
Illusions appear, the patients show a sense of insufficiency, 
and sometimes also a hypochondriac sense of sickness and 
a consciousness of their psychic impediments. 

" In many cases, in which the stupor developed gradu- 
ally, a disturbance of psychomotor activity was observed 
without vivid mental disturbances. On the other hand, 
some cases, recognizing their incapacity for practical life, 
voluntarily committed themselves to the asylum. Most 
cases showed a gradual development of an affectless stupor, 
with a final return to their former mental condition. 
Rarely, psychic impediments develop in a relatively short 
time. The sense of insufficiency may assume a distinctly 
melancholy coloring, with suicidal tendencies. Again, 
severe cases may assume temporarily katatonic symptoms 
of posture and motion sterotypies. 



120 PELLAGRA 

" With this group memory disturbances were especially 
well marked, as Tanzi has emphasized, but weakness of 
memory is not a characteristic of acute pellagrous demen- 
tia. Upon convalescence memory returns easily, so that 
the apparent memory disturbance is due rather to the 
general difficulty of performing psychic processes than a 
weakness. 

" With the relief of the somatic symptoms of acute 
pellagra the mental symptoms also improve. Besides, the 
connections between pellagra and nervous disturbances is 
evident, and different mental symptoms may complicate 
the picture. It would appear that melancholia is the 
typic mental disturbance of pellagra. Tanzi believes that 
we should call such cases amentia, and consider them light 
forms of this psychosis. It is in this group that Tanzi 
would place the typic cases of pellagrous insanity. Stupor 
seems to promise a long duration and an unfavorable prog- 
nosis. Favorable cases lasted from one to six months. 

" Amentia {Acute Confusional Insanity). — These cases 
were long continued, with a tendency to remissions and 
intermissions. After a prolonged period, which shows es- 
sentially the symptoms of the first group, appear usually 
terrifying hallucinations, accompanied by violent motor 
excitement. The delirium was frequently followed by 
stupor or existing stupor was interrupted by delirium. 
The patients see the house or village burning, enemies 
coming, wild animals attacking them, the devil appears, 
or machines cut off their heads. More rarely, they have 
quite dreamy states, the heavens open and the Lord ap- 
pears, bishops, priests, figures pass by. In imagination, 
they return to the scenes of their daily life. Again, they 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 121 

run away to escape the flames or to defend themselves 
against persecution. Here we have phenomena of motion 
in connection with hallucinations. If secluded, they 
move about, are noisy, and knock upon the door. The 
duration of this excitement varies from a few hours to 
several days. These episodes are followed more or less 
by long intervals, in which the patients are quiet in mind 
and body. They may be stuporous, but usually show only 
slight disturbance of orientation. Later, they pass into 
a delirium like that of meningitis or typhoid. If diarrhea 
be present, the complex of typhoid pellagra is recognized. 
This may develop in a chronic case or be an acute process, 
while in rare cases the bodily and mental symptoms may 
improve. Death usually follows this typhoid condition. 
Hallucinations seem to offer for the first attack a de- 
cidedly favorable prognosis. 

" Dementia does not always ensue upon a severe initial 
attack, but develops in chronic cases of either bodily or 
psychic pellagra. The development of kata tonic symp- 
toms, which may appear especially in youthful cases, 
renders the diagnosis difficult. 

" Acute Delirium. — The cases of this group are dis- 
tinguished from those of the third group by the intensity 
of the disease symptoms, hallucinations, motor excitation, 
and shorter courses in death. For this reason the con- 
ception as acute deHrium seems justified. 
m " The symptoms of this condition may occur without 
the bodily signs of pellagra, but they usually occur syn- 
chronously. Absence of a rise of temperature has been 
noted by both Italian and German observers. 

11 Groups 2, 3, and 4 show a great similarity with the 



122 PELLAGRA 

mental symptoms of acute infectious diseases. They might 
therefore, be classified under the infective exhaustive psy- 
choses. 

" Katatonia. — The kata tonic condition occurs with the 
acute somatic pellagra. Here, considering the concurrence 
of acute somatic and psychic pellagra, we must assume a 
pellagrous intoxication as to the causative factor, as in 
pellagrous neurasthenia. Many patients show conscious- 
ness of their disease. Hallucinations may precede this 
condition. Excitement, stereotypy, wild jactitation, and 
verbigeration are common. The katatonic cases pass rap- 
idly into dementia. 

" Of the cases of the fifth group, the majority belong to 
the katatonia subdivision from the symptoms, courses, and 
termination. In three cases (females) excitation occurred, 
ending with stereotypy, jactitation, and verbigeration. 
The patients did not show marked affects. In one case 
hallucinations preceded the condition. In all three cases 
the transition into dementia was rapid, in which posture 
and motion stereotypies, impulsive actions, and talkative- 
ness were observed. In one case these symptoms were 
followed by a permanent negative phase. In another 
case, besides many posture and motion stereotypies, inter- 
change of negativism was observed. In one case the kata- 
tonic symptoms were marked from the beginning. A 
male case showed, on admission to the hospital, katatonic 
excitations, and after a few days a remission followed by 
another katatonic phase. Six of these cases ended in 
dementia more or less rapidly, although remissions oc- 
curred. 

"Anxiety Psychoses. — The violent, fluctuating anxiety 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 123 

effect, the motor unrest, the anxiety ideas, and the ' pho- 
nemes ' completing them, determines from the first the 
diagnosis of an anxiety psychosis. It is true, this disease- 
picture is complicated by extraneous features. The 
patients show a marked sense of insufficiency, appear 
slightly stuporous in the intervals between the attacks, 
and resemble cases of groups 2 and 3. Later the 
anxiety attacks have disappeared, the mental weakness 
increases; the second phase gradually lessens as it does 
in patients of the mentioned group. In the second case 
the psychomotor weakness changed by turns, with violent 
anxiety effects and vivid motor unrest. Temporary ideas 
of persecution and of sin, and, later, of stupor were also 
observed. The third case was typic depressive melan- 
cholia. 

" Maniac-depressive Insanity. — Of the two cases, one 
showed the condition of mania arising from subjective 
pellagrous troubles. In the other, mania was followed by 
distinct stupor." 

The dementia following pellagra shows different forms. 
One form develops an almost complete disappearance of 
mental activity, which justifies the name " paralytic." 
But a milder degree of dementia characterizes the larger 
number of cases. They are oriented, usually well behaved, 
but dull, and showed a lack of self-restraint, with a tendency 
to break out into violent passions and impulsive actions. 
, A simultaneously existing alcoholism has a modifying 
influence upon the disease-picture. Furthermore, in many 
individuals, the pellagrous mental disturbance does not 
appear until old age, and it brings about a precocious senile 
dementia. 



124 PELLAGRA 

There is a distinct pellagrous dementia, like paresis, 
marked with somatic changes. An affirmative answer is 
given to the question, Are there disease-pictures of demen- 
tia whose anatomic basis is an injury to the brain by the 
toxins of pellagra? 

As to the broad classifications of the different psychoses 
of pellagra, probably our most practicable one has been 
given us by Dr. J. W. Mobley, of the Georgia State Sanita- 
rium. He says that his cases fall principally under the 
intoxication or infective-exhaustive group, and he has 
subdivided them under four headings: 

(i) Acute intoxication psychosis, with psychomotor 
suspension. 

(2) Infective-exhaustive psychosis, with psychomotor 
retardation or excitation. 

(3) Symptomatic melancholia, with psychomotor retar- 
dation. 

(4) Maniac-depressive, with psychomotor retardation 
or excitation. 

That the various psychoses are of the most complex 
nature can be inferred from the learned opinions so well 
brought to our notice by Dr. Babcock. That the mani- 
festations of the subtle poison on the psychic centers may 
be influenced largely by temperament, environment, 
previous health or habits, or individual idiosyncrasies is 
admitted. Finally, when we thoroughly understand what 
the toxin of pellagra really is, then may we better read these 
many shades of disturbed mentality, ephermeral or lasting 
as they may appear, and with that knowledge better be 
able to minister successfully to these sick souls. 

So much for the psychology of pellagra. 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 125 

Ocular Symptoms. — While the ocular symptoms in 
pellagra are not distinctive, there are some abnormalities 
that are of interest to consider. 

Dr. E. M. Whaley, of Columbia, studied this aspect, 
and has drawn some interesting conclusions. 

He found that pellagrins did not carry their upper lids 
as high as they should, giving them the appearance of 
lassitude. This has often been noted by the writer, and 
mentioned some months ago. Dilated pupils are not the 
rule, though hypersensitiveness to light with contracted 
pupils was frequently noticed. Shallow anterior chambers 
were found by Dr. Whaley in one-third of the cases. 

A peculiar lack-luster expression of the eyes has been ob- 
served in a majority of the cases, and, in the negroes the 
brownish pigmentation is deepened until it presents almost 
a jaundiced look. Pupillary inequality is not uncommon. 
It may be said, however, that eye symptoms with pellagra 
do not seem to be as frequent in pellagrins in the United 
States as in Europe, according to the reports in hand. 

The thermal phenomena in pellagra have been the 
subject of much study. That the conclusions reached by 
observers of cases in private practice and physicians in 
hospitals or asylums should show a variance is not surpris- 
ing. One writer, in reporting on 100 pellagrins whose 
temperature had been recorded for a month, found more 
or less fever in 80 per cent. This occurred in an asylum, 
arid it is reasonable to suppose that both degenerative and 
inflammatory changes would be found in greater proportion 
than in a given number outside of such an institution. 

It has been the experience of the writer in a large 
number of pellagrins that, in uncomplicated, ambulatory 



126 PELLAGRA 

cases, the temperature was practically always normal or 
subnormal — often the latter. Many of these pellagrins 
easily "caught cold/' which would give rise to a temporary 
rise of temperature, but, apart from the typhoid condition 
of pellagra, which will be considered later, the pellagrous 
process is essentially afebrile. 

Should this disease progress to the " third stage," as 
some classify it, where there is more or less autotoxemia 
exerting its irritating effect on nearly every organ in the 
body, there is, of course, a natural ] tendency to febrile ex- 
acerbations, along with the other abnormal manifestations 
of the diseased body. 

There are occasional fulminant cases, where a high tem- 
perature prevails from the onset of the malady, and where 
a beginning improvement, if the patient is so fortunate as 
to experience it, is ushered in by a decline in the febrile 
symptoms. 

Many of the ambulatory cases habitually run a sub- 
normal temperature in the forenoon, barely getting to 
normal later in the day. 

The writer has records of over 25 of such cases, where 
they were regularly observed in the forenoons, and in but 
few instances was the temperature ever found above 
97-3°F. 

Sandwith positively and laconically sums up this ques- 
tion by saying, " The temperature of an uncomplicated 
case of pellagra is always normal or subnormal." 

The last phase of the different clinical forms in which 
this protean disease is manifested, and the consideration 
of which will close this chapter, is aptly termed typhoid 
pellagra. 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 127 

The fact that pellagrins may and do have typhoid fever 
should be remembered. Watson mentions seeing two cases 
of typhoid in pellagrins in 19 10, and the writer saw one 
typic case in which not a single classic symptom of 
typhoid fever was lacking. 

According to Scheube, typhoid pellagra (typhus pella- 
grosus) consists of an aggravation of all the symptoms, 
especially the mental. His description is as follows, 
" The whole muscular system is in a condition either of 
rigidity or intense tonic contraction. The head is buried 
in the pillows and at times convulsively moved. On spon- 
taneous movement of the limbs a perceptible trembling 
and indications of inco-ordination are made manifest, and 
tremors and fibrillary contractions are seen in the face from 
time to time. The speech is drawling, tremulous, and often 
exhibits a nasal twang. Frequently there are hyperes- 
thesiae and heightened reflex excitability, the tendon 
reflexes in particular being always increased." 

As to the increased tendon reflexes, this has not been 
observed by the writer, but rather the reverse. 

The temperature is generally high, and may run rather 
a symmetric course, not unlike true enteric fever, but this 
typhoidal condition may supervene, progressing to a fatal 
issue without any rise of temperature. 

Procopiu thinks this condition due to the Eberth bacillus 
in the intestines, in which event we have both pellagra and 
tvphoid fever. His views are not accepted by many ob- 
servers. 

The typhoid condition of pellagra generally ushers in the 
terminal stage, and occurs after the patient has suffered 
perhaps several recurrences. There is noticed a more 



128 PELLAGRA 

rapid failure of strength, a more noticeable decline in the 
mental powers, and an increase of all the gastro-intestinal 
symptoms. The abdomen becomes distended, the diar- 
rhea becomes more intractable, and the stools are often 
involuntary and passed without the knowledge of the 
patient. The stools also take on that dreadfully foul 
odor of which mention has been made. The watery feces 
are acrid and irritating, and the mucocutaneous areas in 
and around the anus or vulva become raw, perhaps bleed- 
ing, when cleansed. 

The heart, kidneys, and lungs may become involved as in 
any other acute exhaustive condition, and a low delirium, 
with subsultus, opisthotonos, muscular rigidity, convul- 
sions, and all that melancholy picture of a system suc- 
cumbing to a long-continued toxemia. 

This typhoid condition, which in itself has no relation to 
typhoid fever proper, is nearly always fatal, seldom last- 
ing over two weeks. 

COMPLICATIONS 

In the clinical course of pellagra there are a number of 
complications liable to occur. 

The mental complications have been sufficiently covered. 

In Egypt Dr. Sandwith considers ankylostomiasis an 
almost invariable accompaniment, often joined with bil- 
harziasis. The ankylostomiasis anemia predisposes to 
other complications, as wrist-drop, paraplegia, general 
tumors, epileptic seizures, all following degeneration of the 
spinal cord; also retention of the urine; herpes zoster and 
bronchitis are often noticed. Malaria, too, is a frequent 
complication. 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 129 

In the United States, especially, both the Uncinaria 
americana and the Amceba coli are frequently found in 
pellagra. Among some investigators the ameba has so 
often been found in the stools of pellagrins that a common 
causative factor has been surmised. Pyorrhea alveolaris, 
with accompanying ameba in the pus-pockets about the 
teeth, is not uncommon. Occasionally a supposedly pel- 
lagrous sore mouth with free diarrhea will quickly disap- 
pear under appropriate amebacide treatment. 

One of the most fatal complications is acute alcoholism. 
The pellagrous condition seems to be affected in a specially 
malign manner by alcohol, especially in the form of whisky, 
and it has been frequently noted that hard drinkers al- 
most invariably run a speedy and fatal course. 

About a year ago the writer treated an acute case of 
pellagra in the Tabernacle Infirmary in a robust man 
of forty-five. All the symptoms of a typic case were 
present — the sore mouth and tongue, the erythema on 
arms, feet, and face, the diarrhea, and the mental depres- 
sion — not a symptom lacking. Under the influence of 
treatment he improved rapidly, seeming convalescent in 
about four weeks. He was known to be addicted to whisky, 
occasionally getting under its influence, and he was par- 
ticularly cautioned as to the danger of indulging in this 
stimulant. In spite of his promises, however, soon after 
his return home he fell into an alcoholic debauch, in which 
he exposed himself to the rain and cold, and otherwise mis- 
treated his body. The pellagrous symptoms immediately 
returned with increased virulence, terminating his life in 
less than two weeks. 



130 PELLAGRA 

Syphilis is an occasional complication, but, apart from 
its added burden, has no special bearing on pellagra. 

In Lombardy, where there is much goiter and cretinism, 
we are informed that the physicians there regard one dis- 
ease as the cause of the other. In the United States thyroid 
disease has been noted in connection with pellagra to some 
extent. Dr. D. P. Curry, Sanitary Inspector of the State 
Board of Health of Kentucky, has noted goiter in quite a 
large proportion of pellagrins coming under his care. 

Dr. E. G. Jones, of Atlanta, who has perhaps observed 
more cases of goiter than any one in the South, gives as his 
opinion that concomitant pellagra and goiter are not more 
frequent than concomitant nephritis and goiter, syphilis 
and goiter, or tuberculosis and goiter. He believes, how- 
ever, that pellagra may exert an influence in "lighting up" 
a latent goiter, or that hyperthyroidism may, in the same 
manner, bring out a latent pellagra. 

One of the most difficult complications to manage is the 
condition of marasmus or wasting away, into which the 
pellagrin sometimes lapses. A liberal diet seems to aid not 
at all, and emaciation rapidly supervenes, bringing with it 
apathy, mutism, lessened tendon reflexes, and muscular 
rigidity. 

The writer has at present under observation a case of 
this sort, and, while the patient is eating fairly well and 
being given the most nourishing food, the emaciation is 
progressing, and the prognosis is extremely doubtful. 

Pregnant pellagrins seldom go to full term, generally 
aborting before the sixth month. 

Among the gynecologic complications are amenorrhea in 
the nulliparas and menorrhagia in the multiparas. Among 




Pellagra in the negro. (Case from State Hospital for Insane, Colum- 
bia, S. C.) 



SYMPTOMATOLOGY AND COURSE OF PELLAGRA 131 

other ills in this category are vulvitis, vulvovaginitis, 
cervical erosions, endocervicitis, endometritis, and leukor- 
rhea. Ovarian neuralgia, along with the other nerve 
pains, is present in nearly every female pellagrin. Where 
there have been previous gynecologic troubles, which have 
been seemingly allayed, an onset of pellagra sets up a 
renewal in many instances. 

Appendicitis in the course of pellagra has occurred once 
in the service of the writer at the Tabernacle Infirmary 
Annex (for Pellagra). The patient, a young unmarried 
woman of twenty-five, while apparently progressing favor- 
ably with her pellagrous infection, was suddenly attacked 
with acute appendicitis. Palliative measures having failed 
to give relief, she was operated on by Dr. J. L. Campbell. 
The appendix, which was removed, was hard, indurated, 
and dry. After the operation the recovery was uneventful, 
the wound healing by primary adhesion. The operation 
did not seem to unfavorably affect the pellagrous process, 
while the removal of the diseased appendix exerted a de- 
cidedly beneficial effect on the gastro-intestinal symptoms. 
At present this patient seems to be quite well. 

This practically covers the more frequent complications, 
though in the presence of pellagra, as in any other disease of 
an exhausting character, intercurrent affections are liable 
to crop out at any time. Therefore, while watching for 
the direct and indirect manifestations of pellagra proper, 
k is well to be on the qui vive at all times, lest some unex- 
pected complication, in the already strenuous battle, di- 
minish the outlook for recovery. 



CHAPTER V 

CLINICAL REPORTS AND DESCRIPTIONS OF CASES 
OF PELLAGRA FROM DIFFERENT SOURCES 

The previous chapter has purported to cover the symp- 
tomatology and clinical history of this disease as it has ap- 
peared to various observers in different parts of the globe. 
In a malady of such varying shades it is but natural that 
it should leave different impressions upon the medical 
attendants in closest contact with the sufferers. 

It is thought wise, therefore, to incorporate in this 
chapter a number of clinical histories from widely scattered 
localities, in the hope that the reader may obtain a broader 
conception of this disease entity, whose presence has be- 
come a problem to both the student of medicine and the 
publicist. 

The first report is the graphic description of a case in 
Virginia, as reported by Dr. J. H. Hewett, of Lynnhaven: 

Patient. — H. A. S., London Bridge, Va., aged fifty-six, 
white, widower, occupation milling and farming, was born 
in Charlotte County, Va., reared in Pennsylvania County, 
and remained there the greater part of the time till Feb- 
ruary, 1909, when he moved to Princess Anne County, Va. 
He had spent a year each in Roanoke and Lynchburg, Va., 
where financial reverses made him poor. He also spent 
three years in Nebraska, and then returned to Virginia. 

132 



PELLAGRA FROM DIFFERENT SOURCES 133 

Family History. — The patient's father was killed in an 
accident at the age of forty-eight; his mother died of old 
age at eighty-four. Two brothers are living and well. 
Two brothers are dead — one of " Bright's disease," the 
other of " brain fever." Five sisters are living and well. 
There is no history of cancer, tuberculosis, rheumatism, or 
insanity in any member of the family. The patient's 
father and two of his brothers always suffered from diar- 
rhea whenever they ate bread from corn-meal. 

Personal History. — During childhood the patient had 
diphtheria, measles, mumps, and pertussis. He had ty- 
phoid at eighteen, malaria and gonorrhea at twenty-six, 
grip at thirty-five. Since thirty-five he has always been 
well till the present illness. He has noticed that bread 
made from corn-meal always disagreed with him, even in 
childhood, producing diarrhea and intense intestinal pain. 
His father and two of his brothers, as above stated, were 
also similarly affected by corn-meal bread, but he has no 
knowledge that any of them ever suffered with roughness 
and desquamating of the skin at any time. His average 
weight is 145 pounds. He uses tobacco and alcohol moder- 
ately. He is the father of seven children, all of whom are 
dead. The second child died at the age of thirteen. His 
wife died sixteen years ago. They lived together eighteen 
years. He denies lues. 

Present Illness. — The patient is now a very poor man, 
and for the last three years has been living in cheap board- 
ing-houses or keeping bachelor's quarters, in which he did 
his own cooking. During the latter part of last fall, owing 
to the scarcity of work and the high price of flour, he was 
compelled to eat more and more corn-meal. About the 



134 PELLAGRA 

middle of last December his present diarrhea began, very- 
mild at first, but slowly and steadily increasing in intensity 
until about six weeks ago, when he had from ten to twelve 
movements per day, with agonizing tenesmus and distress- 
ful abdominal pains and nausea. For the last month he 
has ceased to use corn-meal in any form, and the diarrhea 
has considerably abated. Since December he has lost 
about 35 pounds in weight, and has been reduced from a 
robust, virile workingman to a puny, weak, sickly individ- 
ual, to whom life itself is almost a burden. About ten 
weeks ago, while picking strawberries, the back of his 
neck became red and burned as if sunburnt. At the same 
time he suffered with intense headache, which was con- 
fined to the region " behind his ears and extended across 
from ear to ear." This continued for about ten days. 
During this period the skin on the back of neck began to 
peel off. About the same time the skin over the bridge 
of his nose and the side of his face, after having been red 
and painful, likewise began to desquamate in small and 
large dry scales and bran-like particles. About six weeks 
ago the skin on the back of his hands began to look as if 
it was blistered, being swollen, red, and painful, and 
scattered vesicles filled with serous exudates were formed. 
The surface then became quite dry and hardened, cracking 
at all joints and between the fingers. Both hands were 
similarly affected, and about the same extent of surface on 
each involved. In about a week the skin on the back of 
the hands, fingers, and lower third of his forearms began 
to desquamate in the same manner as that on his neck 
and nose. About the same time all the toes of both feet 
became swollen and red. They burned slightly and itched 



PELLAGRA FROM DIFFERENT SOURCES 135 

in a most intense manner. This, however, appeared within 
a week and there was never any induration or desquama- 
tion of any portion of the skin. The gums of his upper 
jaw became swollen and red. There was slight salivation 
for a few days, but this soon disappeared and has not since 
recurred. Since December he has vomited only once, 
that he remembers, but has repeated attacks of nausea 
every day. During the last ten weeks he has had repeated 
attacks of vertigo, often becoming dizzy on rising from 
a sitting to a standing position, or on rising from a recum- 
bent position, and everything becomes black before his 
eyes. 

General Examination. — The patient is a moderately 
emaciated white man, well advanced in years, with a very 
apathetic, listless appearance. He answers questions in a 
slow, whining monotone. He is sitting up, and is able to 
walk around to a limited extent; however, his gait is slow 
and he is evidently very weak. He gives a slight groan 
with each expiration, and appears to be in great distress. 
His hair is lusterless, dry, and straight. The eyes react 
sluggishly to light and accommodation. All of the upper 
teeth have been removed. The lower ones all show more or 
less marked decay. Pyorrhea alveolaris is quite extensive. 
Respiration is slightly labored. The skin everywhere has 
a muddy pallor. The heart, lungs, and thorax show noth- 
ing abnormal. The abdomen is scaphoid in shape. The 
liver, spleen, and kidneys are not palpable. The deep 
reflexes of the upper and lower extremities are increased. 
Plantar stimulation gives a slight dorsal flexion of the great 
toe. No patellar nor ankle clonus can be obtained. There 
is no Rhomberg's sign, but slight tremor on protruding the 



136 PELLAGRA 

tongue. The patient gives no history of urinary trouble 
at any period of his life, though for the past four months 
he has had to get up once or twice every night to mic- 
turate; otherwise, negative. Freshly voided urine shows 
a specific gravity of 1032; deep amber color; sugar and 
albumin, negative. 

Skin. — Over the back of the neck, extending upward to 
the hair-line and downward to level of upper border of the 
soft shirt collar, the skin is of a dirty rose-pink color, and 
everywhere covered with small and medium-sized patches 
of dry exfoliating epidermis. This superficial epidermis 
may be easily removed and no bleeding points remain. 
The same appearance in condition may be noted on each 
side of the neck, extending as far forward as the anterior 
border of the sternocleidomastoid muscle. Similar areas 
over the cheeks, sides and bridge of the nose, and the 
lateral aspect of the forehead fuse and become continuous 
with these areas on the neck. The symmetric situation 
of these lesions on each side of the head is marked. Over 
each side of nose, especially marked in the region of the 
alae nasi, there appears a hypersecretion of the sebaceous 
glands. The orifices of each gland, filled with grayish-white 
sebaceous material, gives the skin a white, stippled appear- 
ance. The surface of the skin over these areas is quite dry 
and rough to the touch. In certain places there is a small 
amount of sebaceous exudate attached to the plaques of 
dead epidermis, giving them the character of thin crusts. 
Along the lower areas on the neck and upper margin of the 
areas on the forehead there is a line of intensified brownish 
pigmentation. The margins of these roughened areas is 
everywhere sharp and well denned. Symmetrically situ- 




Case of pellagra, showing erratic course of the disease. Patient did not 
complain of feeling ill. (Courtesy of Dr. J. W. Babcock.) 



PELLAGRA FROM DIFFERENT SOURCES 137 

a ted on each side of the neck, just below the lower margin 
of the roughened area, is a lenticular-shaped area of deeply 
reddened skin over which the superficial skin appears 
shriveled. These areas, the patient tells me, have ap- 
peared in the last few days, and have the same appearance 
as the large areas when they were first noticed. The 
mucous membranes of the lips and conjunctivas are pale 
but moist. Skin over the chin and the anterior portion 
of the neck appears pale and slightly tanned, but otherwise 
normal. Over the sternum, on the right side, there is a 
lozenge-shaped area, measuring about 5 by 2 cm. ; beginning 
above at the sternoclavicular articulation, extending down- 
ward and inward to the level of the upper border of the 
third rib, there is a brownish pigmented area of desquamat- 
ing epidermis. On the left there is a similar area, but 
smaller. Symmetrically situated on each shoulder, over 
the acromial process, the spine of the scapula, and the in- 
fraspinous fossa, the skin is roughened, harsh, scaly, and 
covered with numerous patches of brownish, desquamat- 
ing epidermis. The skin underlying all of these areas is 
pale, slightly thinned, and very dry and rough. There are 
also similar areas symmetrically situated over each deltoid 
and each triceps muscle. The skin over each olecranon 
process shows the same appearance as that noted above, 
i. e., a dry, harsh, desquamating superficial skin, and a dry, 
pale, slightly thinned underlying skin; but after exposure 
to the sun for a few minutes, as was done when I attempted 
to photograph the patient's hands, the underlying skin 
assumed a rose-pink color, similar to that to be described 
over the hands and arms. The whole surface of both 
hands, especially the backs of the fingers and hands, 



138 PELLAGRA 

and the lower third of both arms, are everywhere quite 
rough and scaly. The skin of the dorsum of the hands, 
wrists, and lower portions of the forearms is of a diffuse 
erythematous rose-pink color. Scattered over these areas 
are innumerable small and large patches and plaques of 
dried and desquamating epidermis. Along all the natural 
furrows of the hands and wrists, at the interphalangeal 
joints, and in between the fingers, there are deep cracks. 
These cracks, the patient tells me, were much deeper a few 
weeks ago. They were also at that time more painful and 
tender, and would often bleed after slight injury. Only 
a few of them now extend through the true skin, and they 
are all healing rapidly. The skin over the sides of the 
fingers and the backs of several of the interphalangeal 
joints is markedly thickened and has the appearance of a 
saw file. The skin on the palms of the hands is pale, but 
the superficial layer is dry and harsh to the touch. In 
places it may be peeled off in large thick plaques, leaving 
a comparatively normal subjacent skin. The line of 
separation between the affected and the non-affected skin 
is sharp and well defined. 

Mentality. — The lady of the house tells me that the 
patient often has fits of extreme irritability, when nothing 
can be done to please him, and he is extremely fault- 
finding and quarrelsome. He shows complete orientation, 
and can remember dates and events accurately, but he has 
to think over many of them for a considerable time. He 
can perform simple problems in arithmetic, but with none 
of the accuracy or rapidity that might be expected of one 
who had once controlled a business house with a capital 
stock of five thousand dollars, as he once did, according 



PELLAGRA FROM DIFFERENT SOURCES 139 

to his story. He complains of difficulty in buttoning his 
shirt and coat, but this is most probably due to the anes- 
thesia produced by the drying and desquamation of the 
superficial skin over the tips of his fingers. 

This word-picture, descriptive of pellagra, as given by 
Dr. Hewett, is hardly lacking in any detail, showing a care- 
ful study of the clinical manifestations and recorded with a 
care for detail worthy of high commendation. The reader 
will do well to study it closely. 

The next case reported is taken from the description of 
Dr. Howard Fox, of New York, a patient, formerly under 
the care of Dr. J. M. Daves, of Blue Ridge, Ga., and seen 
by Dr. Fox through the influence of Dr. Bernard Wolff, of 
Atlanta. 

This case was also seen by Dr. J. J. Watson and Dr. J. 
W. Babcock, who both pronounced it a typic case of pel- 
lagra of rather a mild type. 

Dr. Fox's well-couched description is as follows: 

The patient, H. C. H., is a farmer, fifty-one years old, 
born in Blue Ridge, Fannin County, Ga., where he has 
lived most of his life. His father died at fifty years of age 
of an unknown disease. His mother died at sixty- three of 
the " grip." The patient is the father of thirteen children, 
eight of whom are living and healthy. Four died as in- 
fants. Two of these were twins, two others members of a 
triple birth. One was born dead at full term. The pa- 
tient's wife had never had any miscarriages, and had al- 
ways enjoyed good health. No member of his family had 
ever suffered from a disease similar to the present one. 

The patient had always been a considerable drinker of 
whisky. He gave no history of syphilis, but admitted 



140 PELLAGRA 

having suffered from an obstinate attack of gonorrhea 
when about eighteen years old. At twenty-four he suf- 
fered from an attack of malaria lasting six months. With 
the exception of these illnesses he had always enjoyed good 
health till about two years ago. Since then he had gradu- 
ally " fallen down " in general health and strength. 

The first definite symptoms noted were gradual loss of 
appetite and an occasional " roaring " in the ears. The 
latter symptom had been constant for the last ten months. 
Previous to this time the tinnitus had occurred in attacks 
lasting a few days. 

About the first of April, 1908, the patient noticed a red- 
ness and swelling of the backs of the hands, which he at 
first ascribed to sunburn. The redness was followed by 
scaling, which lasted for two months. There were a few 
" blisters " upon the hands at first, but, except at the out- 
set, there were no subjective symptoms whatever. After 
the disappearance of the eruption the hands looked en- 
tirely normal. During the following winter the patient's 
general health improved. 

About the end of March, 1908, an eruption similar to the 
first appeared on the backs of the hands. This was also 
followed by scaling several weeks later, leaving the hands 
smooth, though darker in color. During the past ten months 
there had been three or four such attacks of redness and 
scaling on the hands. At no time had the hands become 
entirely normal. The attacks had appeared in spite of 
precautions taken by the patient to protect his hands 
from the sun by wearing gloves and by using bland oint- 
ments. There had never been any oozing from the affected 
area nor had there been any subjective symptoms except, 



PELLAGRA FROM DIFFERENT SOURCES 141 

as before said, at the outset of the attacks. Six months 
ago there was an eruption of the face and of the dorsal 
surfaces of the feet somewhat similar to that of the backs 
of the hands. This has now disappeared, leaving the skin 
in apparently normal condition. 

The patient stated that his tongue had been red during 
the past summer. According to Dr. WolfT, it presented a 
fiery-red appearance when seen two months ago. He had 
not suffered from severe diarrhea except for a short period 
of a few weeks recently. His bowels have been " more or 
less loose " during the past summer. 

The patient had become more and more depressed since 
the beginning of his illness and despaired of ever regaining 
his health. He did not suffer from sudden fits of anger 
nor excitement. His memory, according to his statement, 
became very poor. 

Examination showed the patient to be a poorly nourished 
man of medium height. His facial expression was very dull. 
He was slow in answering questions, his memory was evi- 
dently poor, and he was mentally depressed. The pupils 
were equal, moderately dilated, and reacted normally to 
light and accommodation. His tongue was slightly red- 
der than normal. The mucous membrane of the lips and 
mouth were practically normal in appearance. 

The backs of the hands presented a symmetric bluish- 
red area, looking like a fading eczema. This area covered 
the backs of the wrists, extending slightly around the 
radial side to the anterior surface. The distal border of 
the area did not quite extend to the first interphalangeal 
joints. The skin was smooth and had an atrophied ap- 
pearance, though to the touch it did not feel very abnormal. 



i 4 2 PELLAGRA 

The heart, lungs, and abdominal organs were apparently 
normal. The pulse was regular in force and frequency, 
slow, full, and showed marked thickening of the peripheral 
arteries. There was no tenderness over any portion of the 
spine. The gait was apparently normal. There was no 
ataxia. There was some slight rigidity of the muscles 
of the legs. The patellar reflexes were moderately in- 
creased, especially on the left side. There was no ankle- 
clonus, no Babinski reflex. There were no sensory changes 
in the skin. The cutaneous reflexes were normal. Ex- 
amination of the urine showed no abnormal constituents. 

An examination of the blood, made by Dr. Elizabeth 
Finch, was as follows: Hemoglobin (Fleischel), 66 per cent.; 
red cells, 4,264,000; white cells, 9500. Differential leuko- 
cyte count showed polynuclears, 278, 55.6 per cent.; large 
mononuclears and large lymphocytes (22 transitionals), 
16, 38, 7.6 per cent.; small mononuclears and small lympho- 
cytes, 141, 28.3 per cent.; eosinophiles, 37, 7.4 per cent.; 
mast cells, 6, 1.2 per cent. No nucleated red cells. Red 
cells pale, but apparently normal in size. 

An examination of the nose, throat, and ears, made by 
Dr. D. Bryson Delavan, showed the following: " Naso- 
pharynx: Typic chronic catarrhal inflammation of the 
upper nasopharynx and Eustachian tubes, with obstruc- 
tion of the latter. Ears: Condition appeared to be char- 
acteristic of the above. No apparent connection with the 
general disease. " 

After this lucid description by Dr. Fox another case will 
be described, this one by Dr. M. L. Perry, of Parsons, 
Kansas, and reprinted from the Proceedings of the Ameri- 
can Medico-Psychological Association, held at Washing- 



PELLAGRA FROM DIFFERENT SOURCES 143 

ton, May, 1910. Few observers are as able as Dr. Perry 
to paint the shifting changes in the mentality of these 
sufferers. His report follows: 

I. H., white, female, aged thirty-four, single, no occupa- 
tion. Admitted to Osawatomie State Hospital 1901, 
and transferred to Parsons State Hospital 1904. Family 
history negative. Patient had first convulsion at age of 
five months, during an attack of cholera infantum. Fol- 
lowing this acute illness convulsions continued in a light 
form, gradually becoming more frequent and severe as 
she grew older. The first evidence of active mental dis- 
turbances at age of fourteen. On admission patient was 
in vigorous general health, weighing 170 pounds. Feeble- 
minded, with marked facies epilepticus. She had two 
short attacks of acute gastritis in the spring of 1908, and 
severe status in July of same year, otherwise, she remained 
in good general health until the fall of 1909. A note in 
the case record, dated June 19, 1909, says, " A big, strong 
woman, whose health is excellent. Occasionally with a 
severe seizure she has to go to bed for a day, complaining of 
feeling nervous and uncomfortable, and does not rest well. 
Usually is active and a good worker when not cross. Has 
about fifteen seizures per month. Rather loud and bois- 
terous, but most of the time is good natured, although rough 
in her manner and language." 

In September, 1909, she began to complain of not feeling 
well, with vague pains in abdomen and lower extremities, 
anorexia, and some loss of weight. Developed delusions 
that she had been poisoned, and became depressed, refusing 
to eat. Was nauseated, and would induce vomiting at 
times by putting her finger in her throat. Bowels con- 



144 PELLAGRA 

stipated. Tongue furred. Temperature and pulse nor- 
mal. The sensory symptoms, at first vague and more or 
less indefinite, soon became very pronounced. Patient 
complained much of severe pain in abdomen, pelvis, and 
extremities, and soreness on pressure, and was put to bed. 
A note on case record, dated October 18, 1909, says, 
" Patient has complained recently of severe pain, both on 
urination and defecation. Examination showed a very fine 
thick hymen, the opening through which was so small that 
no vaginal examination was undertaken. The mucous 
surfaces about the external genitals were somewhat con- 
gested and sensitive. Examination of the anus showed a 
well-marked fissure, with slightly inflamed mucous mem- 
brane. The fissure was cauterized with nitrate of silver." 
Urine was negative. Patellar reflexes abolished, and she 
soon developed paresthesias in various parts of the body 
and a marked analgesia in both lower extremities. There 
was slight fever present, with pulse somewhat weak and 
accelerated. She had some difficulty in walking, owing 
to weakness and ataxia in lower limbs. A diagnosis of 
multiple neuritis was made and patient treated accordingly. 
There was some improvement observed during the month 
of November, but a note, dated December 1, 1909, states, 
" For several days the patient's condition has been more 
serious, pulse has been hard to count, and general weak- 
ness is pronounced. Has been on strychnin, -$-$ grain 
every three hours, for two days. To-day was given one 
pint of water, by rectum, several times with benefit. She 
has developed a severe stomatitis, which has caused much 
annoyance." Tongue red and fissured, with small blisters 
and ulcers around the edge. Mucous membrane on in- 



PELLAGRA FROM DIFFERENT SOURCES 145 

side of the cheeks also showed ulcers. The inflammation 
extended into the pharynx, making it difficult to swallow 
solid food. Patient at times refused to eat on account of 
sore mouth. Temperature ranged from normal to 100.5 ° 
F. Bowels still inclined to be constipated, although loose 
occasionally for a day. She passed small amounts of puru- 
lent material. Condition of patient varied somewhat 
from week to week, but with no marked change until the 
latter part of January, 19 10. She was able to be up and 
dressed part of the time. The case record shows on Jan- 
uary 30, 19 10, a sudden rise of temperature to 104 ° F., fol- 
lowing a few days of more sensory complaint than usual. 
Fever reduced by sponging. At this time she developed 
an erythema on the dorsum of both hands, particularly 
marked over the knuckles. The hands in a few days be- 
came very rough, with fissures extending through the skin, 
making open sores in several places. No pain nor itching 
of hands present, but they were quite sore when handled. 
The erythema did not extend above the wrist, but there 
were patches on the elbows. At this time a tentative diag- 
nosis of pellagra was made. Some improvement was ob- 
served during the next week, but a note on February 9th 
says, " During the last few days patient has been very 
sick, temperature course irregular, much of the time 
being high, reaching 105 F. on one occasion. She has 
suffered much from severe vomiting. Treatment symp- 
tomatic, cold sponging, strychnin, and nourishment as 
freely as possible." During these febrile attacks there 
appeared a pronounced erythema over nose and cheeks, 
bat-shaped in outline. Later on the skin on both hands 

and face became scaly, and on the hands much thinned and 
10 



146 PELLAGRA 

roughened. There was considerable pigmentation, with a 
quite well-denned line of demarcation at the wrists. Ex- 
amination of blood-smears showed a reduced number of 
leukocytes and considerable evidence of anemia. 

The mental condition of the patient underwent a very 
decided change during her last illness. Her emotional 
state, which had previously been rather exalted, became 
much depressed, with occasional outbursts of pronounced 
excitement, the patient being at times kept in bed with 
extreme difficulty. There was a partial return of the con- 
vulsions toward the end of her illness, and a slight tendency 
to spasticity, but no contractures. Sensory symptoms 
continued to the end. Died April 16, 1910. 

A marked peculiarity of this case is the decided fever at 
times, so different from the usual afebrile condition of 
pellagra. 

The next report is of an Egyptian pellagrin, under the 
care of Dr. Warnock, and reported by Dr. Sandwith : 

An Egyptian woman, aged twenty-one, was admitted 
to the asylum on May 15, 1904, with a history of pellagra 
for the last six months. She was married seven months 
before admission, but her husband had divorced her be- 
cause she wandered about for no reason, was sleepless, 
performed the religious " zikr," talked to herself, and 
used to fall down when she tried to walk. On admission, 
she was sleepless, pulse feeble, tongue could not be seen; 
she had pellagrous rash on her elbows, legs, and tro- 
chanters, and her knee-jerks were greatly exaggerated. 
Her expression was very dull, she complained of being 
ill in her body, and stated that she was possessed by a 
devil. On the same day she had a sort of fit, during 




Egyptian case of pellagra. Markedly indurated skin on back of hands. 
(Service of Dr. Warnock.) 



PELLAGRA FROM DIFFERENT SOURCES 147 

which the attendant stated that she had contraction of 
the limbs and head for a short time, but no loss of con- 
sciousness. She could walk, but refused to stand up when 
asked to do so, and was quite demented, forgetful, and 
unable to converse rationally. She was excited at times, 
incoherent and noisy, but was able to support herself if 
she grasped something to pull herself up by. A month 
later she was still restless, always talking, dirty in her 
habits, but had no definite delusions. In July she still 
had staggering gait, was subject to falls, and her muscles 
were contracted, apparently involuntarily. Her brother, 
who visited her, said that she had had a black rash on her 
face and hands that " would not wash off." Her brother 
denied any syphilis in the family, but had evidently him- 
self suffered from pellagra. In August she was still child- 
ish and dirty in her habits, still obliged to catch hold of 
something to support her when standing up, and her 
speech was still defective, especially the labial sounds, but 
she was more cheerful and beginning to put on weight. 
In November she was fatter, quiet, but still childish, and 
her speech still defective. She was able to walk and in- 
clined at this time to do some work. She laughed inanely, 
and volunteered that she had been under sorcery, induced 
by a man in her village, but the effects had now passed off. 
In December it was noted, " does some work and has some 
sense, but is shy and imbecile in demeanor." In January, 
eight months after admission, she had improved so much 
that she was able to be discharged, quite strong physically 
and able to work, but mentally still somewhat childish, 
thinking she had been under sorcery. 
The following case, which came under the care of the 



148 PELLAGRA 

writer, will illustrate the progress of a seemingly rather 
mild case of pellagra in an aged woman, but which, on 
account of non-resistance, soon resulted fatally: 

Mrs. W. P., aged seventy-one, was seen October 1, 1910, 
and found to be a slender and fragile woman, looking 
fully her age. She was referred by another physician, who 
had noted a rough, scaly appearance of both hands, ex- 
tending up both forearms like a gauntlet. 

Her past history was not productive of interest, except 
that she reported a " spring feeling," as she termed it, for 
the past three years, during which time, for about two 
months in the early summer, she suffered from lassitude 
and slight diarrhea. For this she had gone to the moun- 
tains, each time seeming to obtain relief and strength. 
Being in comfortable financial circumstances, she had been 
able to take every care of herself, and attributed the diar- 
rhea to dietetic indiscretions; the slight erythema she 
thought was caused by exposure to sun and wind during 
her tramps in the mountains. 

Upon physical examination, her heart was found to be 
normal, though the second sound was not very sharp; her 
lungs were normal; her arteries were somewhat sclerosed, 
but her blood-pressure was not high. The arcus senilis 
was most distinct in her eyes. Her stomach was normal in 
size, but ptosed about two inches. Her abdominal walls 
were extremely thin, permitting the peristalsis of the in- 
testines to be plainly seen. Her muscular system was 
flabby, her limbs were wobbly, and her hands tremulous. 
Her voice was quavering and uncertain. There were no 
dermal lesions except on her hands and forearms, these 
showing a rather faded erythema. Her tongue showed 



PELLAGRA FROM DIFFERENT SOURCES 149 

a surface denuded of epithelium around the edges, and was 
pale and tremulous. She did not complain of her tongue 
being sore, but said her taste was not discriminating as it 
had formerly been. At present everything tasted the same 
to her. 

Her appetite was poor, her food seemed to " He heavily " 
in her stomach for several hours after eating, and articles 
that formerly agreed with her seemed to nauseate and dis- 
tress her. Her bowels were loose, moving four or five 
times daily, preceded by colicky pains, the movements 
frothy and foul smelling. She also noted a great difficulty 
in controlling her anal sphincters, on several occasions 
having soiled her linen before she could get to the toilet. 
She admitted being more forgetful than usual,, but her 
husband remarked on her seeming decline in mentality, 
for she had been a woman of fine force of character. 

Treatment seemed at first to aid her, but not for long. 
Her hands began to desquamate, appearing for a time as if 
they were improving, but it was soon noted that the skin 
under the desquamated epidermis seemed to desiccate and 
become rough as soon as it was exposed. Her general com- 
plexion, too, became ashy, her skin taking on a harsh and 
wrinkled appearance. Her diarrhea remained about the 
same, though by October 20th at least half of her move- 
ments were involuntary. Her appetite diminished from 
day to day, so that it was with the utmost difficulty that 
she could be induced to partake of any food at all. This 
disinclination to eat arose both from anorexia and a sito- 
phobia, for she feared the distress that followed each meal. 
Her mouth began to be somewhat sore, and the mucous 
membranes of her lips, before pale, now became a cherry 



ISO PELLAGRA 

red. With failing bodily strength came weakened men- 
tality, and in a dreamy, aimless way she would answer ques- 
tions or make requests pertaining to her comfort. During 
her illness the temperature was never over 98 ° F., and 
generally about 97 ° F. 

With a steady downward course she declined, complain- 
ing but little, and scarcely seeming to realize that she was 
ill. During the last five days of her life, she was semi- 
comatose, her bowels moved involuntarily, her reflexes 
were abolished, dysphagia was marked, her pulse was slow 
and feeble, and she succumbed with hardly a struggle on 
November 12th. 

Had this patient been young and resistant, the disease 
would have probably assumed an entirely different as- 
pect. 

To show how widely variant pellagra may appear, one 
more case, this, too, under the observation of the writer, 
will be cited. As in the first, the whole picture was one of 
weakness and non-resistance, the second will show a 
sthenic form of pellagra, in which a vigorous vitality seems 
to have conquered. 

The patient, Miss A., twenty-four years old, previous 
health good, was seen in July, 191 1, in an apparently 
precarious condition with pellagra. She had lost a younger 
sister two months previously with this disease, the fatal 
result having occurred in the second recurrence. The 
rest of the family were well, and both parents seemed free 
from any pellagrous taint. 

She had always been a healthy, though rather nervous, 
girl, and in the spring of 19 10 she suffered from " diarrhea 
with sunburned hands." The diarrhea, as has so often 




Author's case of pellagra. Patient seems to have recovered. 



PELLAGRA FROM DIFFERENT SOURCES 151 

been the case, was ascribed to errors in diet, and the sunburn 
to exposure. This seemingly slight indisposition disap- 
peared during the summer, and throughout the fall and 
winter she enjoyed her usual health. 

In March, 1911, the diarrhea and erythema reappeared, 
and with the added impression of her sister's illness, being 
much like hers, she began to grow melancholy and appre- 
hensive of dire results. She continued to grow worse, both 
as to the gastro-intestinal symptoms and the erythema, the 
latter showing in symmetric patches on her face, neck, 
breast, and lower limbs. During this time also her parents 
were much troubled by her frequent emotional outbursts, 
and, when the other sister unexpectedly died, they and she 
woke up to the gravity of the situation. 

She was sent to several resorts in the hope of restoration 
to health, but she steadily declined until she was brought 
to Atlanta for treatment. 

When seen by the writer she presented a melancholy 
picture. The erythema was quite extensive in some places, 
mostly on the nose, forehead, and neck, having assumed a 
dingy hue, while the palmar and plantar surfaces had 
become a distinct black, showing an inclination to peel off 
in several places. In several of the interphalangeal spaces 
cracks had formed from which exuded much serum. Her 
tongue, lips, and buccal surfaces were absolutely raw, also 
the vulvovaginal margins and the anal margins. A sero- 
.sanguinolent discharge from the irritated vagina and anus 
kept the inner aspect of the thighs and buttocks almost 
raw, while the relaxed and incompetent anal sphincters 
permitted the watery feces to spurt out at frequent inter- 
vals. 



152 PELLAGRA 

Mentally she was in fully as pitiable a state. A dreamy 
delirium, broken only by horrid dreams and phobias, was 
present, out of which she was aroused with difficulty. The 
reflexes were much exaggerated. Occasionally, when she 
showed lucid intervals, she complained of numbness and 
formication, and was fearful that her heart would suddenly 
stop beating. 

Her temperature for two weeks seldom ran under ioo° F. 
in the mornings, sometimes going up as high as 104 ° F. in 
the evenings. 

Under energetic treatment she began, in about two weeks, 
to show signs of improvement, practically all of her symp- 
toms showing the same uplift. As her bowels improved, so 
did her mind and her erythema, while her sore tongue and 
mouth rapidly lost their fiery red and raw appearance. The 
dry and rough skin peeled off in great flakes, leaving a pink 
and exceedingly tender surface. Her feces assumed a 
semisolid consistency, though she still had to be quite care- 
ful to promptly evacuate her bowels when the desire mani- 
fested itself, or she would soil her linen. 

Her mind also became clear, but she was somewhat 
emotional and easily excited to tears. 

This young patient was in September able to return home, 
and at present is reported as apparently well. Whether 
this improvement will or will not be permanent, time alone 
will tell. 

The description of these several cases in widely scat- 
tered localities covers pellagra in its major and plainer 
forms. The many variations, the many deviations from 
the classic picture, the many atypic or complicated cases, 
will have to be recognized and treated on their merits. 



PELLAGRA FROM DIFFERENT SOURCES 153 

It behooves the thoughtful reader to scan with dis- 
criminating care the many shades of bodily and psychic 
deviations from the normal as set forth here, and the way 
will be paved for a better understanding of the chapter on 
Diagnosis and Prognosis. 



CHAPTER VI 

PATHOLOGY AND MORBID ANATOMY OF 
PELLAGRA 

The morbid anatomy of pellagra is neither constant nor 
characteristic. The chronicity of the disease, the variety 
of symptoms, the many complications and intercurrent 
affections, preclude the naming of any single definite set 
of changes as belonging to its pathology. 

Tuczek, as quoted by Lavinder, described as part ap- 
pearances of cachexia the following: Wasting of adipose 
and muscular tissues, brittleness of the bones (fragilitas 
ossium), atrophy and fatty degenerations of the internal 
organs (chiefly those innervated by the vagus), heart, 
kidneys, spleen, intestines, liver, and lungs. 

He also describes three further groups of morbid changes: 
(i) Intestinal — atrophy of muscular coat, with occasional 
hyperemia and ulceration of the lower part of the tract; 
(2) abnormal pigmentation (similar to senile change), espe- 
cially of ganglionic cells, heart musculature (brown at- 
rophy), hepatic cells, and spleen; (3) ulcerations in the 
nervous system. The variously described conditions of 
hyperemia, anemia, edema, and at times inflammatory 
affections of the central nervous system and its coverings, 
together with the obliteration of the central canal of the 
cord, he regards as not peculiar to pellagra, but as ac- 

154 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 155 

company ing conditions, present in many chronic affections 
of the central nervous system and in senility. 

The findings in the brain are in most cases negative, ex- 
cept for occasional fatty degeneration or calcification of the 
intima of small blood-vessels and pigmentation in the ad- 
ventitial coats. In cases where a long-continued psychosis 
had led to a high degree of imbecility, atrophy of the cere- 
brum may be found. In the cord the changes are fairly 
constant and important: degenerations in the lateral col- 
umns in the dorsal region, and in the posterior columns in 
the cervical and dorsal regions; very few changes are found 
in the lumbar cord. 

Summarizing the data obtained from 153 examinations 
of the cerebrospinal fluid of 106 cases of pellagra, W. F. 
Lorenz, Special Expert, U. S. Public Health Service, reports 
as follows: 

(1) A lymphocytosis of the cerebral fluid does not occur 
in uncomplicated pellagra. 

(2) Globulin excess of the spinal fluid is only occasionally 
observed. 

(3) Lange's colloidal gold chlorid test is uniformly nega- 
tive in pellagra. 

(4) The Wassermann is negative with a few exceptions. 
In this investigation the exceptions were moribund cases 
which gave weakly positive reactions with blood-serum. 

(5) The spinal fluid findings would seem inconsistent 
with a conception that pellagra is an infectious disease of 
the central nervous system. (Public Health Reports. 
Reprint 218.) 

In autopsies performed by Dr. Sandwith, he' noted great 
emaciation and cachexia, generally with marked anemia. 



156 PELLAGRA 

There may be definite exfoliating patches on the parts of 
the body exposed to the sun during life, or there may be 
only a little roughness of these parts, but the skin there, 
if carefully examined, will be found to be atrophied, 
and there is a general diminution of subcutaneous fat. 
Microscopically, there is sclerosis of the blood-vessels, 
papillae, and corium, as well as atrophy of the horny 
layer. 

The muscles, heart, liver, kidneys, and spleen share in the 
general atrophy. 

The lungs sometimes show tubercular lesions. The 
stomach reveals no lesion to the eye, but the walls of the 
intestines are thinner than usual, and show a slight shed- 
ding of the superficial layers of the epithelium, with atrophy 
of the muscular tissue. There is no ulceration of the in- 
testines. Many naked-eye lesions have been reported by 
various observers as occurring in the brain, but the only 
constant one is atrophy of the cortex of the convolutions, 
especially the frontal. 

Dr. Sandwith took from Egypt to England two brains, 
which Dr. Mott examined for him, though they did not 
arrive in a satisfactory condition. There were, however, 
found in them evidences of chronic slight but diffuse 
meningomy elitis . 

Dr. Mott found no decided changes in the spinal cord 
until it was prepared and carefully examined. Tuczek, 
though, in 1893, found in 8 autopsies in Italy that all of 
them showed symmetric sclerosis of the columns of Goll. 
In 6 cases, also, there was lateral ^sclerosis in the dorsal 
region, and in 1 case he found cervical anterior sclerosis. 

In 1899 Dr. E. F. Batten made, for Dr. Sandwith, many 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 157 

sections of three pellagrous cords, and furnished the follow- 
ing report on them : 

Marches Method. — The paleness of the posterior columns 
was very noticeable, but under the microscope no recently 
degenerate fibers could be seen. The cells of the anterior 
horns were pigmented. 

Weigert-Pal Method. — The lack of fibers in the poste- 
rior columns was very marked, both sacral and lumbar re- 
gions being affected equally. In the mid-dorsal region a 
pair of normal roots entered the cord, and wedged itself in 
between the atrophied fibers of the median and external 
columns; this root could be traced up to the upper cervical 
region, where, again, the incoming roots contained more 
normal fiber. A small wedge-shaped tract was also visible 
just outside the anterior horns of the cervical region. 

Aniline-blue-black Method. — The increase of the con- 
nective tissue in the posterior columns was very marked, 
and distributed itself in exact correspondence with the con- 
dition of the roots above described, namely, a pair of 
roots, which had undergone no degeneration in the dorsal 
region, showed no increase of the connective tissue in 
the area it occupied in the cord. There was no increased 
vascularity of the cord, the cells of the anterior horn and the 
nucleus and nucleolus were distinct, the increase of the 
connective tissue was limited to the posterior columns, ex- 
cept in the wedge-shaped tract above described in the 
cervical region, which appeared darker owing to the small- 
ness of the film in this area. 

Van deserts Method. — There was no evidence of any 
recent inflammatory action in the gray matter. There was 
some thickening of the walls of the smaller vessels, espe- 



158 PELLAGRA 

daily in the posterior columns, though it was not limited 
to this region. 

The posterior roots of the cervical, dorsal, and lumbar 
regions were also examined in this case by Marchi, Weigert- 
Pal, and Strobe's methods. Marchi's method showed very 
little recent degeneration, though it was obvious, from the 
lack of staining, that a very considerable amount of de- 
generation had taken place, and this was made evident 
by staining by the Weigert-Pal method. The greatest 
amount of destruction seemed to have taken place in the 
dorsal and lumbar regions, and to a lesser extent in the 
cervical region; the same condition was also shown by 
the Strobe stain; only a few axis-cylinders could be seen 
in each root. 

This patient died of pellagra and chronic kidney dis- 
ease, but there was no possibility of knowing how many 
years she had suffered from pellagra. 

According to Dr. Sandwith's opinion the cord degenera- 
tion would appear to be of root origin, and affects the 
extramedullary as well as the intramedullary portion of 
the posterior roots. The degeneration in the cervical re- 
gion of this cord was most marked in the columns of Goll, 
the columns of Burdach being affected to a lesser degree. 
Since then he has had many other sections cut and ex- 
amined by experts, but, unfortunately, nothing of patho- 
logic interest was revealed. The absence of cord degenera- 
tion in these cases was due to the fact that the patients had 
either had pellagra for too short a time — one year or less — 
or that, though they had suffered from pellagra for three 
years or more, the clinical signs of the disease were not 
very far advanced. In other words, spinal cord degenera- 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 159 

tion, as discovered by the microscope, is a comparatively 
late lesion in the disease. 

The following remarks from a recent paper of Dr. J. D. 
Long show his views as to certain pathologic lesions in pel- 
lagra: 

" As to the lesions on various parts of the body, in every 
case of pellagra in which radiographs were made the plates 
showed deposits in the spinal foraminse which apparently 
produced pressure on the nerves. As to the part played 
by toxic degeneration of the nerves themselves, I can only 
repeat what I was told by Dr. Achucaro, of the Govern- 
ment Hospital for the Insane, Washington, D. C, that 
experiments show, when various tissues, such as nerves, 
muscle, and fat, are allowed to decompose, that the nerve, 
being the most highly specialized of all the tissues, shows 
evidences of degeneration first. 

" It is possible that several factors may be concerned 
in the seasonal recurrence of the disease: first, renewed 
activity and renewed infections with amebae in the spring 
of the year; second, engorgement of the intestines, due to 
chilling of the body surface; third, the growth of molds in 
food products, with resulting changes in these products, 
which could favor fermentation in a person already de- 
bilitated. 

" As to the degeneration of the posterolateral columns of 
the spinal cord, Marie made the observation that the de- 
generation began in the posterior of the spinal nerves. The 
radiographs showed that the pressure does come on the 
posterior roots of these nerves at about the site of the 
ganglion. Further, at the only autopsy I could obtain, it 
was noticed that the foramina were so filled with what 



160 PELLAGRA 

seemed to be a firm cartilage-like deposit that the nerves 
were wedged therein, and a large-sized sewing-needle or a 
Japanese tooth-pick could not be pushed through the 
foramina. The spinal canal was also partially filled. 

" It may be seen from the skeleton and the radiographs 
that the foramina, in the cervical region decrease in size 
from above downward, whereas the nerves increase. 
These facts would seem to account for the lesions on the 
hands (fifth, sixth, seventh, eighth cervical, and first 
dorsal), face, and neck (third and fourth cervical). 

" With reference to the dorsal nerves, Gray says, ' The 
roots of the dorsal nerves are of small size, and vary but 
slightly from the second to the last.' Examination of the 
skeleton shows these foramina to be larger than the lower 
cervical, and, therefore, there are no lesions on the parts 
innervated by the dorsal nerves. 

" The lesions on the legs and feet are due to pressure 
on the first and second sacral nerves, of which Gray says, 
1 The roots of the upper sacral nerves are the largest of all 
the spinal nerves, while those of the lowest sacral and coc- 
cygeal nerves are the smallest.' The foramina are larger 
than the other intervertebral foramina, but are more 
tortuous, and, as the spinal canal in the sacrum is incom- 
plete posteriorly and flattened, it is possible that any de- 
posit here will produce pressure- symptoms as in the other 
vertebrae." 

Dr. J. C. Bardin, pathologist of the Central State Hospi- 
tal, Petersburg, Va., has recently made postmortems on 
5 cases of pellagra, and has carefully investigated the 
blood in 14. He has rendered a most interesting account 
of his findings in the October issue of the American 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 161 

Journal of Insanity, and the following are abstracts of his 
article: 

He considers that pellagrins are specially prone to con- 
tract tuberculosis — particularly intestinal tuberculosis — 
and seem to be an easy prey to intestinal parasites at nearly 
every stage of the disease. The pellagrous lesions of the 
intestines naturally render them more vulnerable to any 
organism that might happen to enter. Dr. Bardin opines 
that cases of intestinal tuberculosis occurring in patients 
suffering with pellagra cannot be detected, save in rare 
instances, until postmortem is done. 

In the American Journal of Insanity, July, 1913, Dr. 
Bardin commented on the marked eosinophilia in pellagrins 
infected with intestinal parasites, which, however, does not 
affect the lymphocyte counts. He further remarks: "One 
who has not observed the feces of negroes can have no idea 
how heavily they are sometimes infected with these organ- 
isms; and it is to be wondered at that more of our cases of 
pellagra do not show this condition." 

Were it possible to give a definite sequence of tempera- 
ture to pellagra, so that it could be differentiated from 
tuberculosis, it would be possible, by keeping charts of all 
patients in the diarrheal period, to detect those com- 
plicated by tuberculosis of the bowel. Unfortunately this 
has not been practicable. 

Three out of the 5 cases examined postmortem showed 

tuberculosis of the bowel, and a fourth showed healed lesions 

of the lungs. Another case, that did not die, was diagnosed 

tuberculosis of the lungs, and was sent to a tuberculosis 

colony. While recovering from tuberculosis, pellagra 

developed. This patient went through a typic attack of 
11 



162 PELLAGRA 

pellagra, but both the pellagra and tuberculosis improved 
during the same time, and the recovery from both seemed 
complete. 

The writer does not doubt that tuberculosis complicates 
many of these pellagrous cases, especially those with per- 
sistent diarrhea. In analyzing the findings in 14 cases, 
considerable discrepancy was found to exist between the 
blood of those pellagrins having tuberculosis and those 
not having it. The discrepancies occurred principally 
in the differential leukocyte counts. 

The blood examinations were made by Dr. Bardin, as 
far as possible, while the pellagrous symptoms were at 
their height — that is, when there was marked diarrhea, 
erythema, and stomatitis. In making the red and white 
counts the usual technic was employed, and at least six 
different fields were counted and averaged in each ex- 
amination. A variation of six leukocytes was allowed be- 
tween the highest and lowest field counts. At least four 
white counts were made in each case and the results aver- 
aged. 

The results of the several tables gotten up by Dr. Bardin 
show that there is usually a well-marked reduction in the 
number of red blood-cells, a diminution in the percentage 
of hemoglobin, and but little change in the leukocytes in all 
the cases. 

The differential counts show a variable reduction in the 
percentage of polymorphonuclears; a marked variability 
in the percentage of small lymphocytes; a fairly constant, 
but small increase in large lymphocytes; and a marked 
diminution in eosinophiles. 

Leaving out some interesting tables showing the blood- 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 163 

counts in cases complicated by tuberculosis, we find that 
Dr. Bardin observed that in uncomplicated pellagra the 
small lymphocytes seem to be increased in proportion to 
the severity of the skin lesions, though this does not always 
hold good. He has also observed that the more chronic 
the case, the more small lymphocytes there will be rela- 
tively. He has been struck with one or two things in cases 
of uncomplicated pellagra that occur with too great a 
regularity to be accidental. They are an increase in lymph- 
ocytes, with a corresponding reduction in polymorpho- 
nuclears and a marked reduction in eosinophiles. These 
variations from the normal blood-picture seem fairly con- 
stant. Further than this Dr. Bardin does not commit 
himself. 

The studies of the cytology of the blood by Drs. 0. S. 
Hillman and P. A. Schule have not disclosed any con- 
stant abnormality. A lymphocytosis was observed in 
approximately 75 per cent, of the cases examined by them. 

The writer is able to obtain a personal report from Dr. 
E. C. Thrash, of Atlanta, who has recently held four post- 
mortems on pellagrins whose illness has lasted a variable 
length of time. As a result of these postmortems he has 
formed certain conclusions embodied herein. The result 
of all profound anemias is a cloudy swelling of the cell 
structures of the various organs of the body with other 
atrophies. This is so not only of toxic conditions result- 
.ing from poisons emanating from organic living matter, 
but also from chemical poisons. There is no exception to 
this rule in pellagra. 

In the more acute cases there is hyperemia and cell 
migration in the brain, liver, spleen, and kidneys. In 



164 PELLAGRA 

those assuming a chronic condition there are atrophic 
changes that simulate those changes which take place 
following albuminous degeneration of cell structures re- 
sulting from other toxemias, which are complete atrophy, 
vacuolization, degeneration of the nucleus characterized 
by failure to take the basic stains, infiltration of pigment 
(brown atrophy), and abiotrophy or partial death of the 
cells. 

The brain especially shows this condition, there being 
cell degenerations in the cortical structure of the brain and 
lateral and posterior columns of the cord, the cell degenera- 
tions here mentioned. When the nobler cells are degener- 
ated or completely destroyed, there is infiltration of con- 
nective-tissue stroma to supply the void caused by the 
death of these cells. This accounts for the excessive 
amount of neuroglia tissues found in the cortical structure 
of the brain, and especially in the lateral and posterior 
columns, causing the pathologic findings in this disease to 
simulate locomotor ataxia. This same degenerative 
process takes place not only in the brain, but in the kid- 
neys, liver, spleen, and, in a measure, the muscular struc- 
tures, especially the heart, as in one case there was a 
brown atrophy of the heart musculature much simulating 
senility. 

Intestines. — In two of these cases examined the intes- 
tines showed conditions which were somewhat different 
from reports ordinarily given in postmortem findings. 
There was no ulceration and but little change in the ap- 
pearance of the intestinal mucosa, except a decided thick- 
ening of the intestinal walls in certain areas. The micro- 
scopic examination showed that this thickening was due to 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 165 

an infiltration of fibrous tissue, the musculature having 
almost entirely disappeared. The mucosa showed but 
little change except that of chronic inflammation char- 
acterized by atrophy and disappearance of some of the 
columnar cells, and infiltration of connective-tissue stroma, 
which stroma had numbers of foci of amyloid degenera- 
tion. Whether this was a terminal condition resulting 
from long-continued illness and cachexia which might have 
appeared in other diseases, Dr. Thrash could not say. 
His observation and findings led him to believe that the in- 
testinal and stomach disturbances in pellagra are secondary, 
resulting from nature's effort to be relieved of poisonings 
which have been ingested, and which have resulted from 
perverted metabolism and various atrophic changes of all 
the cell structures of the body. 

This condition must be relieved by the emunctory 
organs, and they, suffering from the changes mentioned, 
must naturally be unable to perform their function, and 
necessarily the alimentary tract would have extra demands 
made upon it, which brings on the train of symptoms with 
which we are so familiar. 

Since the first edition of this book was published, Dr. 
Thrash, in his postmortem work at Grady Hospital, has per- 
formed a number of autopsies on pellagrins, and his later 
findings present no notable additions to his previous re- 
port. 

Passing on to some of the special organs, we note cer- 
tain morbid conditions obtaining in most cases of pellagra, 
though not invariably, and some of these changes are found 
nearly, if not fully, as often in some other diseases. 

In Lombardy, edema of the lungs, pleurisy, hyperemia, 



1 66 PELLAGRA 

emphysema, and pneumonia were frequently found in 
conjunction with pellagra. Tuberculosis was rare, though 
there may have been some local reason for this. With 
us, in this country, tuberculosis in pellagrins is not un- 
common. 

In many autopsies brown atrophy of the heart muscle 
has been observed, also frequent softening of the myocar- 
dium. Apart from this, no special pellagrous lesions of 
the heart have been found. 

Lesions of the liver are rather common. Sometimes 
it is small, sometimes it is large and friable, and brown 
atrophy occurs. In 29 autopsies made in Italy there were 
7 cirrhoses and 9 fatty livers. Sometimes the weight of 
the liver is diminished by half. Fatty infiltration is often 
found, and congestion or granulofatty degeneration. 

The spleen is often atrophied, occasionally hyper tro- 
phied. There have been atrophied spleens noted even in 
typhoid pellagra. 

Seldom are normal kidneys found in pellagrins. They 
may be fatty, atrophied, cirrhotic, or cystic. In over 
half of the cases the weight of the kidneys is diminished. 
Often asymmetric renal sclerosis is present, and fatty de- 
generation of the epithelium of the tubules is found, with 
or without interstitial sclerosis. 

Fragility of the bones of the skeleton has been noted by 
several observers. This fragility is supposed to depend on 
the eccentric atrophy of the compact substance with 
hypertrophy of the medullary substances, and has been 
seemingly demonstrated by the microscope. 

The main skin lesions, as described by Grimni, consist of 
marked atrophy of the stratum corneum, copious desquama- 



PATHOLOGY AND MORBID ANATOMY OF PELLAGRA 167 

tion, active reproduction in the Malpighian reticulum, and 
marked sclerosis of the vessels of the papillary layer and 
the derma. 

Pigmentary degenerations are frequent, some of which 
have been already noted. There may be found brown 
atrophy of the heart, pigmentation of the liver cells, pig- 
mentation of the cerebral vessels and of the spinal and 
ganglionic cells. In one case there was observed a general 
pigmentation of the kidneys, heart, liver, and the vessels 
of the brain. 

The calcareous degeneration of the cerebral vessels, the 
thickening of the membranes of the brain and of its vessels, 
help to explain the frequent psychic disorders which almost 
invariably accompany pellagra. 

Also, as was noted by Dr. Thrash, the tendency to ather- 
oma and precocious senility is one of the most remarkable 
and frequent pathologic changes in pellagra. 

The pathology has by no means been worked out to any 
definite status in pellagra, and the writer has been forced 
to gather to the best advantage the sometimes divergent 
views of different observers. 



CHAPTER VII 

DIAGNOSIS, COURSE AND PROGRESS, AND 
PROGNOSIS OF PELLAGRA 

DIAGNOSIS 

After so much has been written concerning the clinical 
history and symptomatology of pellagra, it might be sur- 
mised that to diagnosticate this malady would be an easy 
matter. This is so in typic manifestation, as it is in typic 
manifestations of any other disease entity. 

To one who has mastered the rudiments of diagnosis 
and symptomatology, such diseases as variola, measles, 
pertussis, and others that might be mentioned, would 
offer no difficulty were their pathognomonic symptoms 
squarely and openly exhibited. 

Thus, with pellagra, when the erythema, the diarrhea, 
the depressed mentality, and the nerve pains all come to- 
gether, the diagnosis is thrust on the physician nolens 
volens. The very many atypic cases, however, that are con- 
stantly cropping up, together with the great importance 
to the patient of an early diagnosis, make it highly essen- 
tial that as clear a diagnostic picture as can be possibly 
drawn should be presented to the student of this ofttimes 
puzzling and perplexing malady. 

Viewing it in perspective, we might say that pellagra pre- 
sented a fourfold syndrome, the presence of at least two 

168 



DIAGNOSIS 169 

units of which would be necessary in order to make a diag- 
nosis. Oft times two are not quite sufficient for a positive 
diagnosis, though they furnish reasonable certainty, and a 
tentative diagnosis is justified. Three of the group would 
make out quite a strong case, while all four being present 
would render the diagnosis an absolute certainty. 

According to the views of the writer, who has given 
the diagnosis much thought, it is most practicable to di- 
vide this fourfold diagnostic syndrome into the aspects of 
gastro-intestinal, dermal, nervous, and psychic. 

It should be remembered that there is no definite rule as 
to the appearance of any one of these factors at any spe- 
cific stage of the disease. For instance, there may have 
been vague gastro-intestinal disturbances, intermittent in 
character and punctuated by periods of seemingly perfect 
health. Some of these patients may have suffered from 
digestive ailments irrespective of the pellagrous onset for 
a number of years, so that the gastro-intestinal symptoms 
may seem but an exacerbation of the original chronic 
trouble. 

In a not inconsiderable number of well-developed cases 
of pellagra, if care is taken to bring it out, a history of 
slight, almost ephemeral, " sunburns," occurring in pre- 
vious springs or summers, and occasioning neither discom- 
fort nor anxiety, may be elicited. In many pellagrins, who 
perform manual labor, men who work in the open, who 
.are exposed to the vicissitudes of the weather, or who 
handle heavy burdens; women who perform laborious 
household duties, who scrub, wash dishes and clothes, whose 
hands are much in hot water, and whose busy feet can hardly 
keep pace with the constant demands, these pay but scant 



I ;o PELLAGRA 

attention to slight erythemas, dismissing them with hardly 
a passing thought. 

Again, the dermal manifestations are occasionally late 
symptoms, preceded by one or more of the other factors, 
and only needed to " clinch " the diagnosis. However, to 
wait for these might cause the patient to lose precious time 
— time which might spell the difference between recovery 
and death. 

The manifold symptoms of nerve-irritation, appearing 
in such varied guises, may be easily mistaken for many 
pathologic conditions. The lightning pains of tabes 
dorsalis; the disquieting pangs of an incipient sciatica; the 
reflex neuralgias from previous inflammatory lesions; the 
nervous rumblings from an ancient gumma, which per- 
haps has reposed in a state of " innocuous desuetude " 
for years — such as these may mask the nervous picture, 
and also cause a loss of valuable time. 

In the psychic factor of the syndrome, the actual be- 
ginning of the deviation from normal is probably the most 
difficult of all. To fairly judge temperamental changes; 
to estimate slight lapses of mental poise; to differentiate 
between a dissatisfaction or a slight delusion, or between 
a real dislike or an obsession of distrust; to estimate the 
various grades of unhappiness, extending from hardly 
realized mental depression to deep melancholia or positive 
forms of insanity — these, too, will tax to the uttermost 
the skill and acumen of the conscientious student of this 
disease. 

Another caution may appropriately be given in regard 
to making diagnosis of pellagra on insufficient evidence. 

When several cases have appeared in some community, 



DIAGNOSIS 171 

and rumors as to its spread are rife, there is sometimes a 
tendency to diagnose certain illnesses as pellagra, when a 
more careful analysis would have shown the obvious errors. 

Within the last six months the writer has seen diag- 
nosed as pellagra such troubles as pyorrhea alveolaris, with 
sore gums and irritated tongue, but not another pellagrous 
symptom; tuberculosis of the intestines, with chronic diar- 
rhea, but no erythema or psychasthenia ; aphthous stoma- 
titis; marasmus with profound anemia; simple melan- 
cholia; and one case of acute mania, where there was ab- 
solutely no excuse for such a mistake. In the last-men- 
tioned instance the patient, a woman, became suddenly and 
wildly unbalanced mentally. There was no diarrhea, no 
history of indigestion, no erythema — nothing but a dis- 
turbed mentality, which was manifested by a violent de- 
lirium, and which later on ended in recovery. 

To diagnose such cases as pellagra, with all that this 
diagnosis entails, is unjust to the patient, and liable to 
reflect seriously on the attending physician's judgment. 

When a suspected case of pellagra presents itself, the 
history should be carefully taken and the following points 
noted : 

Has there been a history of indigestion at irregular in- 
tervals without apparent cause? Have certain articles 
recently disagreed that formerly agreed with the patient? 
Has the patient suffered with anorexia, or colicky pains, or 
'diarrhea, or tenesmus? Have there been vague or active 
neuralgic pains, or has there been burning of the hands, 
feet, tongue, or buccal membranes? These symptoms, if 
present, are exceedingly suspicious. Has there been a 
sense of malaise or weakness in the preceding spring, or 



172 PELLAGRA 

any previous springs or other seasons of the year? If this 
malaise has been present in the spring or summer, has it 
cleared up in the fall and winter? Has there been any 
" sunburn " of the hands or face or neck, or has there been 
any " chapped " hands or lips, which later on seemed well, 
but left for a while a tender pink surface? Has the tongue 
been sore, or have there been any " mouth ulcers " or sore 
lips or cheeks? Have there been any spells of "blues" 
or periods when it seemed everything went wrong? An- 
other question, to which the patient cannot give a correct 
answer, is regarding any change of disposition or feeling 
toward those near and dear. It has been often found 
in the mental perversion of pellagra that antipathies 
would spring up against those closest by ties of blood and 
companionship. 

Has there been insomnia, followed by an intense melan- 
choly? Has fear of impending danger or a vague, undefined 
sense of ill-being brought about unhappy days and " nights 
devoid of ease "? Has the disposition seemed to undergo 
a transformation, so that a formerly cheerful temperament 
has lapsed into an unhappy and morose personality? 
These and others of like import are needed to bring out 
the salient points in the diagnosis of pellagra. 

The following combined symptoms are strongly indicative 
of a positive diagnosis of this disease: 

A symmetric erythema of either the hands, forearms, 
sides of neck (rarely), sides of nose (rarely), sides of fore- 
head (rarely), or the dorsal surfaces of both feet. The 
writer recalls no case of pellagra presenting a one-sided skin 
lesion. This erythema may be only a decided blush, not 
extending below the epidermis, but it must be symmetric, 



DIAGNOSIS 173 

scaly, rather rough, and present a distinct line of demarca- 
tion at the junction with the healthy skin. Should the 
erythema be more pronounced, showing the surface of a 
dull pink, as if it had been " baked in a stove," should the 
dorsal surfaces of the hands appear rather " shiny," pos- 
sibly merging into cracked and tender interphalangeal 
spaces, with dry, rough and scaly feel, and dingy brown or 
black palmar surfaces, this would constitute a formidable 
link in the chain of evidence. The erythematous patches 
on other parts of the body are not pathognomonic unless 
in conjunction with the others mentioned. 

Should there be in addition to this erythema, a sore 
tongue or mouth, cherry-red and tender lips, inflamed 
buccal surfaces; tongue red and inflamed on the top or 
around the edges and denuded of epithelium, aphthous 
ulcers on the tongue or in the buccal cavity, with dys- 
phagia either from soreness or " nervousness," this makes 
still stronger the first link in the chain. 

Next come the gastro-intestinal symptoms, to which 
attention has been called. Should the patient complain of 
indigestion, to which is added colicky pains, and especially 
a diarrhea, apparently causeless, spasmodic, tending to 
involuntary evacuations, but little affected by what is 
eaten and exceedingly foul, another link has been added to 
the pellagrous bill of indictment. 

If, in addition to the other symptoms, the patient should 
complain of shooting pains in the head or limbs; of pares- 
thesias, or formications, of anesthetic or hyperesthetic 
areas ; of intense burning of the mouth, tongue, hands or feet, 
or any other part of the body; if the locomotion was un- 
steady or impaired; if tremor appeared in the hands or 



174 PELLAGRA 

tongue; if there are dizziness with the eyes closed or fear 
of walking in the dark on account of pedal anesthesia, still 
another link is added. 

If, in corroboration of the previous symptoms, there 
is more or less mental depression, verging into melan- 
choly, or deeper forms of psychic abnormality; if the tem- 
perament has undergone a decided change; if there are 
doubts, fears, or obsessions where there were formerly 
courage, fortitude, and a clear vision of men and affairs; 
finally, if mental failure goes apace with bodily cachexia, 
the picture may be considered complete, the links in the 
chain of pellagrous evidence uninterrupted, doubts may 
be cast aside, and the diagnosis may be made with entire 
assurance. 

Where two factors in this syndrome are plainly mani- 
fested, it is sometimes perfectly safe to make a diagnosis of 
pellagra; for instance, if there is the characteristic erythema, 
coupled with an indigestion and diarrhea. The nervous 
and mental symptoms may be absent, but the other evi- 
dence may be sufficient. Again, there may be present a sore 
mouth and tongue, presenting the pellagrous appearance, 
and there may be diarrhea and gastric distress in evidence. 
In such an instance, while the presumptive evidence is 
strong enough to warrant putting the patient under treat- 
ment for pellagra, it would hardly be safe to make a posi- 
tive diagnosis unless either the erythema or nervous or 
mental symptoms entered in evidence. 

The writer recently diagnosed a case upon the evidence 
of slight nervousness and a mild erythema. The other 
symptoms were absolutely lacking, but the erythema was 
so symmetric and characteristic that no doubt was enter- 



DIAGNOSIS 175 

tained as to other symptoms showing up later on. This 
expectation was realized about two months later, when a 
colicky diarrhea set in. 

Whether or not a physician is justified in making a diag- 
nosis of pellagra when there are at no times in the course 
of the illness any eruption, is an open question. " Pellagra 
sine pellagra " is a term that is odious to some, impossible 
to others, and ridiculous to a few. The writer feels that 
it is possible for a case to run a certain course without any 
eruption, but he would be exceedingly chary in diagnos- 
ticating such a manifestation unless the other three factors 
in the fourfold syndromes were present beyond a perad- 
venture. 

Scurvy, leprosy, beriberi, and syphilis have been mis- 
taken for pellagra, but should be easily differentiated, if 
care is taken. 

Chronic mercurial and arsenic poisoning should show but 
little difficulty in elimination from a pellagrous diagnosis. 

Some food or occupation poisonings need occasionally 
to be differentiated, but the development is generally dif- 
ferent and the pellagrous syndrome is incomplete. 

Occasionally, when the disease assumes a typhoid char- 
acter rather early in its course, it is possible to confound it 
with one of the infectious diseases, but proper analytic 
precautions will generally suffice to clear up the diagnosis. 

This presentation of the diagnostic syndrome, together 
with the other aids, as previously laid down, is thought by 
the writer to be full enough to enable any thoughtful ob- 
server to recognize pellagra. 



176 PELLAGRA 

COURSE OF THE DISEASE 

A part of this has been already covered in previous chap- 
ters, but some of the features require additional discussion. 

Pellagra is essentially a chronic disease, and in minor 
degrees may lurk in the system for many years. One 
writer has expressed the belief that some cases have lain 
latent for as long as thirty years, only to take on an added 
pathologic impetus, rapidly proving fatal. Many are 
the reports of cases lasting five, ten, or fifteen years, where 
the recurrences are unmistakable. These intermittent 
pellagras in robust persons, where the habits are good 
and the environment favorable, may run an almost in- 
definite course, permitting the sufferer to die of some other 
ailment. 

In the majority of cases the first manifestation of any 
sort appears in the spring of the year, and either disap- 
pears by summer or fall, or decreases in severity. In 
this apparently prodromal stage the physician is seldom 
consulted, or if so, is generally consulted for some other 
supposed illness. 

Should there be any eruption, it is, as stated, ascribed to 
other causes. 

The writer agrees with Dr. Harris, in part, as to many 
cases of chronic " dyspepsia," diarrhea, or obscure debility 
that have come on from year to year, not quite making 
an invalid of the sufferer, but preventing a full adapta- 
tion to all the requirements of active life, being, in reality, 
instances of " corn-bread poisoning." 

In the opinion of most of the students of pellagra, it is 
never fatal in its first appearance, and will either intermit 
or remit of its own accord. 



COURSE OF THE DISEASE 177 

It is in the second, third, or later recrudescence that the 
toxin seems to have gained a sufficient momentum, as it 
were, to wreak serious damages. It is then that the differ- 
ent factors in the syndrome begin to assemble, and the pic- 
ture of pellagra begins to assume pathologic shape. 

• Pellagra seems essentially a disease of hot weather. 
While not all the deaths from this cause occur during the 
heated term, the vast majority do, and those who have 
had experience know full well how all the symptoms of 
improvement are hastened with the advent of cold weather, 
and even the fulminant cases seemingly halted in their 
progress toward a fatal termination. There are, of course, 
exceptions to this, but they are few — not more than the 
exceptions in other chronic seasonal diseases. 

Having passed the incubative stage, or the prodromal 
stage, or pellagra of the first degree, as denominated by 
different writers, the disease assumes the second stage, or 
becomes, as Strambio calls it, " confirmed pellagra." 

This stage in the course shows a deepening of the pre- 
vious symptoms in nearly every particular, and, unless 
checked, generally progresses to a fatal termination. 

The following quotation from Casenave, written over 
fifty years ago, may be fitly used in this connection, as 
showing the difficulty in making any definite classification 
of the course of pellagra: 

" The division of pellagra into commencing, confirmed, 
and inveterate is not a practical one, for pellagra may be 
beyond hope from its commencement. The expressions 
period and degree, which convey the idea of certain fixed 
symptoms and appearances, are not adapted to the descrip- 
tion of a disease so capricious. The term degree seems 
12 



178 PELLAGRA 

to indicate an increasing intensity, while the second or 
third appearance of the disease may be less severe than at 
first. When we employ these terms, therefore, we shall 
use them only as symptoms of a more or less advanced 
step of the disease, for, like every other disease, pellagra 
has a beginning, a progress, and a termination." 

An added difficulty in following the course of pellagra 
lies in the absence of well-marked lines of demarcation 
between the different so-called stages. The intermittent 
may imperceptibly merge into the confirmed, or even the 
apparently confirmed may seem to improve into the re- 
mittent or even the intermittent form. 

When a patient reaches this stage, however, the pellagra 
seldom remains stationary; it either decidedly improves 
or the reverse. The condition has become so intolerable 
that efforts are made for relief, so that either amelioration 
of the trouble ensues, or the general system shows an in- 
ability to cope with the poison. In this stage, also, the 
mental abnormalities either deepen or clear up, and the 
various psychoses are liable to become confirmed. 

Should the progress be unfavorable, a general cachexia 
may set in, sapping practically every organ in the body. 
By active treatment this cachexia may be halted or even 
driven back, but when pellagra has advanced to the deeply 
cachectic state, with weakened mentality, it may safely be 
assumed that trophoneuroses have taken place, in which 
degenerations and scar tissue lie behind the open mani- 
festations. 

There is the utmost difference between the progress 
of pellagra in robust individuals, with healthy ancestry, 
good habits, hygienic environment, financial ability to 





Unusual pigmentation in pellagra. Patient died ten days later. (Courtesy 
of Dr. J. W. Babcock.) 



PROGNOSIS 179 

provide nutritious food, and intelligence to so regulate the 
mode of life that the diseased body can wage a strenuous 
fight with the toxins that seek to destroy it. These are 
the cases who enable the physician to furnish optimistic 
reports concerning pellagra, and, were it not for such as 
these, the usual progress of pellagra would be most dis- 
couraging. 

The ravages of this malady in some of the congested and 
poverty-stricken localities of Europe have caused many to 
consider it a disease of poverty. This is an error. It is a 
disease of all classes, but its progress among the physical 
or mental weaklings, among those who cannot stop long 
enough in the battle for bread to deliberately and sys- 
tematically fight this monster — these are the stricken ones, 
who yield to its every inroad and who permit its rapid 
advance. 

We may sum up the progress of pellagra by the state- 
ment that in many instances its course is most erratic, 
but that in normal individuals it is an extremely chronic 
disease, and that a duration of from five to fifteen or even 
twenty-five years is not uncommon. 

PROGNOSIS 

It may be emphasized at the outset that pellagra in any 
degree, however seemingly slight, is a serious disease. 
The simplest manifestation is a proof that there lurks in 
tfre system a subtle, a mysterious, an intangible toxin, one 
whose lair has not as yet been located, or whose intimate 
composition been understood. We are, therefore, in a sense, 
fighting an unseen enemy, and until this enemy is forced 
into the open, we must necessarily rest in an uncertainty. 



180 PELLAGRA 

Our experience with pellagra in the United States has 
been too limited to form reliable conclusions as to its mor- 
tality, most of our few statistics being based on asylum 
records. It is natural to suppose that such statistics would 
be very high, for none but the advanced cases are sent 
to asylums — cases where trophic lesions have done their 
destructive work, or where cachexias have sapped the scant 
vitality of the invalid. 

Asylum statistics to date give the startling mortality of 
67 per cent., though this is not based on a very large 
number of cases. 

Statistics on non-asylum cases in the United States have 
not been collated in sufficient numbers to furnish any 
definite or reliable information, but the writer feels that 
there is much reason for optimism as to the future outlook 
of the situation, and little excuse for the attitude of wooden 
pessimism assumed by some, who are supposed to be in a 
position to speak with authority. 

Lombroso, as quoted by Dr. Lavinder, stated that in 
1883 there were treated in 866 Italian civil hospitals 6025 
pellagrins, of whom 923 died; in 1884 there were treated 
in 993 hospitals 6944, of whom 780 died, thus giving, in 
this large experience, an average case mortality of nearly 
13 per cent. 

Wollenberg (Public Health Reports, July, 1909) estimates 
from reports he considers fairly reliable a total of 55,029 
cases in Italy in 1905, with a total mortality of 2359, a 
mortality of a little over 4 per cent. Allowing for possible 
errors, this does not seem such a very gloomy report. 

Early cases, those recognized before cachexia has set in, 
cases in the intermittent stage, where periods of seeming 



PROGNOSIS 181 

health intervene between the pellagrous manifestations; 
cases where little involvement of the nerve-centers is ap- 
parent; cases which possess enough intelligence and perse- 
verance to continue treatment for a long time; cases with 
strong ancestry, without syphilitic or other hereditary 
taint — these individuals may rightly cherish strong hopes 
for ultimate and complete recovery. 

Other factors of important prognostic import relate to 
habit and environment. Those who are not willing to 
regulate their daily habits strictly along hygienic rules 
as laid down by the medical attendant may expect un- 
satisfactory progress, frequent relapses, and probably an 
unfavorable termination. Probably the most dangerous 
indulgence is that of strong drink. Alcoholic beverages, 
unless in the smallest and most attenuated form, are 
poisonous to pellagra, and it is wise to inform the patient 
of this fact without any quibbles. The writer would 
not feel justified in giving any " steady drinker " a hopeful 
prognosis, no matter how early in the disease the true con- 
dition is recognized. 

Again, if the pellagrin can spend the heated term in a 
cool locality, the outlook is greatly brightened. Unfor- 
tunately this is impossible in many instances. 

Speaking generally, it might be said that the earlier 
the disease is diagnosed and treatment begun, the more 
favorable the prognosis. 

. The amount of skin involvement is not a fair criterion 
of the gravity of the invasion, though a clearing up of 
these lesions is to quite an extent an index of improve- 
ment. 

The chronic types, where there have been several recru- 



182 PELLAGRA 

descences, but neither cachexia nor mental involvement, 
may be considered as hopeful. 

Pellagra being ordinarily an afebrile disease, the pres- 
ence of fever, particularly if decided or persistent, may be 
looked on with grave apprehension. 

The nervous, and especially the psychic symptoms 
furnish more reliable indices as to underlying trophic 
changes or degenerations. Therefore, where marked men- 
tal symptoms supervene, where a melancholy or a settled 
gloom pervades the temperament, or, worse still, if demen- 
tia with loss of reflexes complicates the situation, the out- 
look is correspondingly darkened. 

The writer always gives a guarded prognosis in cases 
with mental involvement, and advises his readers to do 
likewise. 

Another form in which death may be confidently pre- 
dicted is the so-called typhoid pellagra. When, in the 
course of the pellagra, there appears opisthotonos, rigid- 
ity of the legs, delirium, albuminous urine, with ammoniac 
odor of the perspiration, tremors, and fibrillary contrac- 
tions, accompanied by high temperature, the end is not 
far off. 

There are certain complications which exert a decided 
bearing on the ultimate result; among these are malaria, 
intestinal parasites, nephritis, acute bronchitis, pneumonia, 
bed-sores (often impossible to avoid), tuberculosis of the 
bowels, pregnancy, or any acute intercurrent affections. 

Occasionally, after the patient seems on the road to 
recovery, a severe recrudescence, without apparent cause, 
greatly clouds the prognosis. 

As in any other chronic affection, pellagra renders the 



PROGNOSIS 183 

body more vulnerable to infections or epidemic diseases. 
The physician should always bear in mind that in pellagra 
we are treating a disease entity, the etiologic foundation 
of which is not settled, and until this " consummation de- 
voutly to be hoped " is realized, we should in every case 
be exceedingly careful as to promises of recovery. In ad- 
dition, remembering its seasonal character, a full year, 
unbroken by any pellagrous symptoms, should elapse be- 
fore an opinion as to cure should be expressed. Especially 
is it to be desired that the patient should pass the following 
spring and early summer with no sign of a recrudescence. 
Should this fortunate state of affairs take place, where 
the skin lesions have disappeared, where the digestion 
seems normal and the diarrhea has abated; should the 
drooping spirits regain their wonted vivacity, and the 
wasted body put on again a liberal amount of adipose 
tissue, and should this improvement last for a year or 
more, the pellagra may be considered cured, and the pa- 
tient may reasonably indulge in the hope that the mysteri- 
ous poison has departed never to return. 



CHAPTER VIII 

THE TREATMENT OF PELLAGRA— A DISCUSSION 
OF DIFFERENT METHODS 

It is admitted at the outset that a specific treatment for 
pellagra has not been found. 

When, in any disease, a multiplicity of remedies are 
laid down, it is proof positive that one sovereign remedy 
has not been discovered. This is unfortunately true to a 
degree in pellagra, but the accumulated experience of many 
students with methods, empiric and otherwise, has not 
been barren of results, so we feel that the therapy of this 
malady has been removed from the realm of mere guess- 
work, and that many of the symptoms we can attack with 
a feeling of confidence born of past successes. 

In this chapter some of the views of different investiga- 
tors will be discussed, but the writer will give a full ac- 
count of the therapeutic procedures which (in his and the 
experience of those whose opinions he values) have yielded 
the best results. 

Lombroso was the first to formulate any definite treat- 
ment, and some remarks made shortly before his death 
had a prophetic ring. He said, " The therapy of this 
disease, which was at first desperate, and could be summed 
up in baths barren of result, can now be undertaken more 
confidently and rationally, as the treatment of a chronic 
intoxication, analogous to alcoholism or morphinism, and 

184 



DIFFERENT METHODS OF TREATMENT 185 

curable by antidotes, when the use of the toxic material 
has been suspended. These antidotes are probably to be 
found in arsenic and chlorid of sodium." 

The teaching of Lombroso has met with deserved re- 
spect, and many of his ideas have formed the basis of the 
present therapy. To attempt to cover this subject without 
a review of the measures recommended by him would 
render the chapter incomplete. 

He recommended a liberal diet, including a full allow- 
ance of meat; though in the well nourished he did not con- 
sider it so necessary to push the feeding. He also recom- 
mended baths and cold douches for the paretic state, the 
chronic skin lesions, and the neuritis manifested by burn- 
ing sensations. In those, however, where a repugnance 
to baths was manifested he did not insist on hydrotherapy. 
He did not favor iron, for he seldom saw benefit arise from 
its use, while he often saw it exert an unfavorable in- 
fluence on the gastro-intestinal symptoms. Acetate of 
lead he tried out, rinding it of no avail except in pellagra 
of the aged. In typhoid pellagra he obtained no benefit 
from any procedures. 

Finally, Lombroso thought of arsenic, and, after experi- 
menting with it for a while, he came to the conclusion 
that in it he had found a most valuable remedy — not an 
absolute specific, but a remedy that acts somewhat as an 
antidote. In this particular he compared the action of 
.arsenic to that of opium in alcoholism or mercury and the 
iodids in syphilis. Sodium chlorid he also used with 
some satisfaction, but seemed to think its best effect was in 
children. In using this drug (arsenic) he either admin- 
istered Fowler's solution, beginning in 5 -drop doses and 



186 PELLAGRA 

increasing to the physiologic limit, or arsenous acid 
(arsenic trioxid), dissolved in slightly alcoholized water in 
doses of 4V m g- U P to the point of tolerance. When the 
well-known physiologic effects appeared he would suspend 
the drug for a few days, begin with the minimal dose, and 
gradually work upward again. 

Among the types which he thought arsenic benefited 
were cases with marked marasmus; cases with incipient 
paresis; cases badly run down as a result of sitophobia; 
cases with vague mania, but not systematized delirium; 
cases in aged people, if not too senile. 

Among the class of cases which derived little benefit from 
arsenic were children and robust cases; cases with systemat- 
ized deHrium; cases with mental alienation of extreme 
chronicity; cases complicated by lobar pneumonia, tuber- 
culosis, nephritis, or severe and oft-recurring vertigo. 

Among the symptomatic remedies of his armamen- 
tarium were calomel, bismuth, castor oil, opium, tannin, 
and chlorate of potash. He also advocated strychnin and 
faradism, and in restless or maniacal cases he used opium, 
chloral, or paraldehyd as hypnotics. 

While he claimed that even empirically arsenic had 
proved its beneficial effect, he also claimed that rationally 
it could be prescribed on the grounds of its tonic and 
" alterative " effect on the heart, skin, and nervous system, 
besides its antifermentative power in the alimentary 
tract. 

His methods — hygienic, dietetic, and medicinal — have 
served in many ways as a beacon light, which still casts 
its rays on the therapeutics of the present time. 

To review all the literature to date advocating countless 



DIFFERENT METHODS OF TREATMENT 187 

remedies, some of them more bizarre than reasonable, would 
demand a useless expenditure of the reader's time. Such 
will not be attempted, but some of the contemporaneous 
literature will be abstracted in order to show that the rank 
and file of the medical profession have not slept over this 
problem. 

The first comparatively non-toxic preparation of arsenic 
was atoxyl, probably first used by Babes, and it seemed to 
give quite satisfactory results. Following atoxyl came 
soamin and arsacetin, all trade names for sodium arsanilate, 
and containing from 22 to 26 per cent, of this drug. 

It would appear that the arsenic in these preparations 
is liberated very slowly in the system, thus obtaining the 
wished-for therapeutic effect minus the toxic. Atoxyl 
and the other trade preparations of its class were claimed 
to exert only about the fortieth toxic effect of arsenic 
trioxid, but in several instances unfavorable effects were 
noticed, among others degeneration of the optic nerve, 
resulting in blindness. Koch, who was at first a strong 
advocate of atoxyl, after getting several cases of blindness 
from its use, and feeling that small doses were valueless, 
gave it up. 

Those who used this preparation began in doses of 
J to 3 gr., given hypodermically every alternate day, 
and increased until the single dose reached as much as 
10 gr. 

- Arsacetin, or sodium acetyl arsanilate, was much more 
soluble than atoxyl, would stand heating so that it could 
be sterilized, and was given in doses ranging from 1 to 7 gr. 
hypodermically. 

Babes thought well of atoxyl from his experience in 



!88 PELLAGRA 

Roumania, while Warnock, who used it in the asylum at 
Cairo, Egypt, was at first quite enthusiastic over his results. 
Later reports, however, were not so unanimous in its 
praise, and in one of his papers Warnock wrote, " It may 
be said that the value of atoxyl in the advanced stages 
of pellagra, such as are met with in this asylum, has not 
been demonstrated." 

Among American observers, who have not been pleased 
with atoxyl after extensive trial, are Wood, of Wilmington, 
and Babcock, of Columbia. 

Soamin is still being used in some quarters with satisfac- 
tion, but the writer does not believe that atoxyl or arsacetin 
is at present being administered to any great extent. 

Among the next therapeutic procedures to attract at- 
tention was transfusion of blood, as advocated by Cole and 
Winthrop, of Mobile, who were the first in this country 
to champion it successfully. 

These investigators proceeded upon the assumption that : 

"Pellagra is an intoxication, the toxic principles exist- 
ing in the blood of pellagrins. 

" The production of pellagrous symptoms by the injec- 
tion of blood from pellagrins, the definite precipitative, 
hemolytic, and antitoxic action of the serum, the artificial 
immunity produced in animals, and the immunity acquired 
in patients recovered from pellagra, are all suggestive of a 
serum treatment in the solution of the pellagra problem. 

" Antonini and Marianni used pellagrous serum hypo- 
dermically with apparently good effects, so much so that 
Lombroso, in a manner, indorsed their efforts. " 

Cole and Winthrop, believing that the blood of a healed 
pellagrin possessed all the curative powers of the serum, 



DIFFERENT METHODS OF TREATMENT 189 

besides having a tendency to improve the anemia in severe 
cases, transfused quite a number, with seeming remarkable 
effects in some of the cases. 

They report the following conclusions: 

" (1) In certain severe cases of pellagra resisting all 
forms of medical treatment transfusion has been followed 
by recovery with no relapse. 

" (2) The patients recovering showed marked improve- 
ment from the first; in the fatal cases there was no benefit 
from transfusion. 

" (3) Transfusion is of undoubted value in certain severe 
and apparently hopeless cases, but without a thorough 
knowledge of the technic of transfusion, and without a 
careful selection of the cases and donors, it will be brought 
into an undeserved ill repute." 

Possibly, for the reasons mentioned, this operation has 
fallen somewhat into disrepute, and perhaps undeserv- 
edly. It must be admitted that some apparently hopeless 
cases have suddenly showed marked improvement after 
transfusion, and the writer trusts that, with the improved 
technic, etc., as advocated by these gentlemen, transfusion 
may still hold a worthy place in the treatment of certain 
selected cases. This procedure must always be employed 
by a careful surgeon and under favorable surroundings, 
otherwise it will prove disastrous. 

At present, few, if any, advocate transfusion, except as a 
dernier ressort. 

Dr. A. C. Cudd, of Spartanburg, S. C, has reported three 
appendicostomies with irrigation of the colon for pellagra, 
and feels that decided improvement was obtained in two 
of them. 



190 PELLAGRA 

Another surgeon, whose name has escaped the writer, 
has advocated cecostomy and irrigation in pellagra. 

These radical surgical operations, while they may aid in 
the elimination of toxins from the intestines, must necessar- 
ily be limited in their application, and will probably not be 
used to any great extent. 

The idea that the colon is the most frequent habitat of 
" pellagrous germs," and that its thorough irrigation will 
aid in the systemic ehmination, is not a new departure, but 
has been frequently mentioned by the older writers. It 
may be stated as a general principle, however, that any 
agencies assisting in cleansing a filthy colon exercises to 
some degree a helpful influence on pellagra. 

Drainage of the gall-bladder has been advocated and per- 
formed in Atlanta quite recently, but the cases have been 
too few and the time too short since the operations to arrive 
at any definite conclusions as to their effect on the disease. 

Along with many other systemic infections for which sal- 
varsan has been employed is pellagra. It has almost be- 
come the custom in some quarters, when other remedies 
fail, to use salvarsan empirically, hoping that in some un- 
explained way benefit might ensue. Dr. E. H. Martin, of 
Hot Springs, Ark., strongly advocates both salvarsan and 
neosalvarsan, claiming the former to be 35 to 50 per cent, 
more curative than the latter. 

The writer has seen it injected in several cases, and has 
reports on over eighty instances, where it was employed in 
practically every stage of pellagra, from the mild to the 
typhoid, and the consensus of opinion is that it is useless, 
unless syphilis enters as a complication. 

No other special surgical treatment has been suggested. 



DIFFERENT METHODS OF TREATMENT 191 

We will now take up the general treatment of pellagra in 
its different phases: First, the treatment of the disease as 
an entity; second, treatment of the special symptoms, of 
which there are many, and of the complications, of which 
the same may be said. 

The general treatment naturally divides itself into: (1) 
dietetic; (2) hygienic; (3) hydro therapeu tic ; (4) medicinal; 
(5) climatic. 

Dietetic Treatment. — Until the theory regarding the eti- 
ology of pellagra is clearly settled, and the present zeist 
views as to some products of spoiled corn being responsible 
is exploded, it would appear the part of wisdom to give our 
patients the benefit of the doubt by excluding from the 
dietary, so far as possible, all articles of food made from 
corn or corn products. We say " so far as possible," for, 
as has been previously mentioned, there are so many adul- 
terated food products on the market in which some deriv- 
ative of corn is the adulterant that we cannot always be 
sure that corn is really absent from our daily food or drink. 

This would also apply forcibly to the dietaries of various 
institutions, especially those for nervous and mental in- 
valids. 

In the early manifestations of diarrhea, this symptom 
being in the main compensatory, a restricted diet has but 
little influence, though, of course, the ordinary care as to 
food with a large amount of irritating residue should be 
noted. This applies only to the early diarrhea before in- 
flammatory changes of the intestinal mucosa have occurred. 

Pellagra being both chronic and exhausting, active sup- 
portive measures are indicated from the very outset. 
Every patient with pellagra, no matter how light it appears, 



192 PELLAGRA 

may be considered to have entered into a long and taxing 
battle, and his daily caloric requirements should be guarded 
most zealously. 

Along this line should be stressed the caution that when 
certain articles of food of which the pellagrin is fond are 
prohibited, the medical attendant should see to it that 
these articles are replaced by something else with an equal 
caloric value, or the nutrition will seriously suffer. 

The writer has observed a number of patients where one 
article after another has been eliminated from the daily 
dietary without being replaced specifically, until the 
patient was not ingesting enough for an infant in arms. 

The diet should be easily assimilable, highly nutritious, 
and it might be added that pellagrins seem to bear spe- 
cially well the flesh proteins. 

It has been the experience of the writer that all along 
through the course of the disease meats are well borne, and, 
even in those conditions where there is much active gastro- 
intestinal irritation, they agree better than in a like amount 
of irritation from other causes. Tender broiled steak or 
roast beef, lamb, or other roast meats may be given twice 
daily, or, if the mouth is too sore to chew, either the scraped 
beef or that ground in a sausage mill may be served. This 
also applies to the white meats, and, if the suggested grind- 
ing of the meat is carried out, it is as little irritating as 
possible to the inflamed buccal membrane. 

As a sample diet in Italy may be mentioned that at the 
Locanda Sanitaria at Bagnolo Mella. It is as follows: 
First meal, meat broth and coffee and milk, each on alter- 
nate days, with 150 grams of bread. Second meal, one 
liter of soup made of macaroni, 100 grams of vegetables, 



DIFFERENT METHODS OF TREATMENT 193 

100 grams meat stock and condiments; boiled meat, 200 
grams; vegetables, 50 grams; bread, 300 grams; wine, 200 
grams. Third meal, one-half liter of soup made of rice, 
50 grams; vegetables, 50 grams; meat stock and condiments, 
100 grams; vegetables, 50 grams; and wine, 200 grams. 
This diet is modified in many ways to suit individual tastes 
and idiosyncrasies, and reduced in quantity for children 
under twelve years of age. 

Eggs are generally permissible, though, if there is a 
flatulent tendency, it is well to give only the whites. The 
albumen of raw eggs may be prepared in various ways, 
limited only by the ingenuity of the nurse, being flavored 
with orange, lemon, grape, or other juices, and when pre- 
pared this way seldom disagree. These egg-albumens are 
most valuable in the exhausted typhoid conditions, and may 
be administered early and often. 

Sweet milk is valuable when it agrees, but, unfortunately, 
many pellagrins show an idiosyncrasy against it. Flatu- 
lence frequently follows its ingestion, and in many patients 
the stomachs furnish enough rennin to promptly coagulate 
the milk, but are tardy in disintegrating the curds, so there 
is present a sense of weight and discomfort in the epigas- 
trium. Peptonizing the milk usually obviates this, but few 
pellagrins relish peptonized milk. 

One highly esteemed confrere recommends for pellagra 
forced feeding, consisting of six raw eggs and three quarts 
of sweet milk daily, both being increased until at least a 
gallon of milk and ten or twelve raw eggs are consumed 
in the twenty-four hours. This would be practicable in 
a not very large proportion of cases. 

Buttermilk is a most useful article of diet, seldom up- 

13 



194 PELLAGRA 

setting the stomach or intestines. The artificially soured 
milk, or lacteal champagne, containing all the fat, is often 
not only well borne, but acts as an appetizer. 

Where constipation is in evidence, oatmeal, tender vege- 
tables in puree form, thoroughly baked Irish — not sweet — 
potatoes, or cereals with but little sugar will aid the peris- 
talsis of the intestines. 

Later on in the course of the disease, when inflammatory 
lesions have set up in the intestines, or a chronic gastritis 
complicates the situation, the diet should be suited to the 
condition, remembering, though, that to some extent the 
gastro-intestinal tract will bear more in pellagra than when 
similarly inflamed from other diseases. 

Barley-gruel, rice-water, the lighter cereals, thick broths 
with scant condiments, malted milk and egg, dry meat 
powders, dry albuminized powders, with butter up to the 
patient's ability to eat — this is a general summary of the 
later diet. 

Olive oil, in §- or i -ounce doses at intervals, will often 
help the abdominal cramps, while the addition of an egg to 
each portion of the olive oil will greatly swell the daily 
calories. 

The following dietary is recommended by Dr. Joseph 
Goldberger in his last report, January 15, 1915, and coin- 
cides to a remarkable extent with that advocated by the 
writer as far back as 1909: 

"Milk. — Fresh milk alone or in alternation with butter- 
milk should be given freely. It is probably the most valu- 
able single food, and adults should be urged to take not less 
than 1 \ to 2 pints in the twenty-four hours. 

"Eggs. — Fresh eggs should be allowed freely. In addi- 



DIFFERENT METHODS OF TREATMENT 195 

tion to the milk and meat, an adult should take not less 
than four eggs a day. In certain of the severer forms it 
may be necessary to give the eggs in the form of albumen- 
water, preferably with orange or lemon juice. 

"Meat. — The meat should be fresh lean meat. Whether 
all fresh meats are equally valuable in treatment we do not 
know; future studies will have to determine this. Our ex- 
perience has been with beef alone. This may be served as 
scraped beef, as a roast, or as steak. Where mastication is 
painful, meat, juice may be given instead. An adult should 
be urged to take at least a half pound of lean meat a day in 
addition to the milk, eggs, and legumes. It may be neces- 
sary in some instances to work up gradually to the point 
where these quantities can be taken. 

"Legumes. — We have been much impressed with the 
favorable results following the use of beans and peas alone. 
The beans and peas should be fresh or dried, not canned. 
The palatable pea or bean soup should be prepared and 
should be given freely. In addition to or in alternation 
with the soup the beans or peas should be served and eaten 
in any one of the other well-known forms. 

"In cases presenting marked gastro-intestinal symptoms, 
the diet of the patient may be limited to the foregoing 
articles. It may here be emphasized that diarrhea is no 
contraindication to the full feeding. 

"In cases presenting only moderate or no gastro-intestinal 
symptoms there may be added, in restricted amounts, oat- 
meal, rice, and barley as cereals, potatoes and onions as 
fresh vegetables, fresh or dried (not canned) fruits, and 
wheat or rye bread or biscuits. 

"As long as symptoms of pellagra are perceptible we pre- 



196 PELLAGRA 

fer to exclude all corn products; not that corn is not a 
wholesome and nutritious food, but because the occurrence 
of pellagra is commonly, though by no means exclusively, 
associated with the consumption of a diet in which corn 
forms a disproportionately large part. Similarly, a reduc- 
tion in the amount of other carbohydraceous articles, such 
as the newer cereal breakfast foods, molasses, jams, or 
starch, should, we think, be ordered, if on analysis of the 
patient's prepellagrinous dietary some such articles or com- 
bination of articles appear to have formed a very conspicu- 
ous proportion of the diet. 

"After all symptoms of pellagra have disappeared, corn 
and other starchy foods in moderation and guarded with 
an abundance of milk, meat, or legumes, and, preferably, 
with all of these, may unhesitatingly be allowed." 

The experience of the writer has rendered him chary in 
the use of alcohol in pellagra. It would appear that the 
possible fuel and food value of alcohol is more than counter- 
balanced by its malign effect on the gastro-intestinal 
mucosa, as has been noted in a number of instances where 
this agent was added to the dietary in apparently conva- 
lescing cases. In exceptional cases, when whisky or brandy 
are deemed necessary by the physician, they should be well 
diluted, and be given as milk-punch, egg-nog, or with grape- 
juice or lemonade. 

Practically the same may be said concerning the alco- 
holic proprietary food preparations. As an aid to the daily 
regimen or to tide over some dietetic emergencies some of 
them are useful. 

During intercurrent attacks of vomiting, when no food 
can be retained, or where more solid nourishment is omitted 



DIFFERENT METHODS OF TREATMENT 197 

during the night, calling for some slight stimulant, they 
fill an indication, but as a dependence to supply daily caloric 
requirements they are a " delusion and a snare." To 
furnish sufficient calories with these preparations alone 
would keep the patient in a state of alcoholic coma plus 
all the resultant evils reflected on the whole alimentary 
tract. This is no imaginary picture, but has been impressed 
on the writer by observation of some melancholy in- 
stances, where zeal had outstripped discretion, and where 
evidences of alcoholic intoxication were thoughtlessly 
attributed to other causes. 

To wisely adjust the daily regimen to each individual 
case, respecting idiosyncrasies, likes and dislikes is no easy 
task, and will require both time and patience. The prob- 
lem of the bodily up-keep in pellagra is of basic importance, 
and should never be lost sight of from the beginning of 
the management. Its successful solution will in most in- 
stances decide the ultimate prognosis, marking the differ- 
ence between recovery and death. 

Hygienic Treatment. — In no other chronic or exhaustive 
disease is there a greater necessity for hygienic habits than 
pellagra. At best the patient has an up-hill fight, and both 
body and mind need every aid that can be afforded. 

One of the first hygienic considerations is rest. As far 
as practicable this should be enforced, while any evidences 
of bodily weakness, nervous irritation, or mental instabil- 
ity are evident. The patient should be put to bed for a 
while, and every disquieting factor removed. Good ven- 
tilation, not too much fight, freedom from disturbing 
noises, cheerful companionship, and all that train of help- 
ful influences that prevent confinement being so irksome 



198 PELLAGRA 

are indicated. In those cases where it is not possible to 
obtain complete rest, active exertion should be avoided, 
and the judgment and tact of the attending physician 
invoked so as to meet the exigencies of the situation. 

In the neurasthenic or mentally disturbed class of pel- 
lagrins, complete rest is absolutely essential, and no marked 
or lasting benefit may be expected without it. 

In this division of treatment may with propriety be men- 
tioned the avoidance of light — sunlight in particular. 

The rays of the sun, especially in the spring time, seem to 
exert a peculiarly irritating effect on the erythema. The 
patient should be cautioned to keep out of bright sunlight 
as much as possible, and, when out-of-doors, to protect the 
hands and forearms with gloves, and the face and neck with 
a broad hat, veil, or umbrella. 

It has been observed many times that an improving ery- 
thema, or even a comparatively normal skin surface, will 
quickly flare up on injudicious exposure to the rays of the 
sun. 

The use of the Rontgen ray, either for diagnosis of any 
condition or therapeutically, should be absolutely inter- 
dicted during the course of pellagra, and for at least one 
year after all symptoms have disappeared. Even a brief 
fluoroscopic examination is dangerous. 

The writer has reported two cases (American Journal of 
Rontgenology, November, 19 14) in which, after exposure 
to the rays, violent pellagra promptly developed. In 
neither of these patients was pellagra suspected previous 
to the Rontgen examination. 

As there is good reason to believe that latent or atypic 
pellagra may be fiercely precipitated by the Rontgen ray, 
its employment should be avoided in all suspicious cases. 



DIFFERENT METHODS OF TREATMENT 199 

The patient should be enjoined to thoroughly masticate 
the food, so as to put no undue burden on the gastro-in- 
testinal mucosa. Parenthetically, in this connection, 
might be noted the advisability of putting the teeth in 
order. A regular examination of the oral cavity will re- 
veal many foul conditions, where tender or defective teeth 
or pyorrhea alveolaris not only render effective chewing 
impossible, but a constant supply of pathogenic bacteria 
from this cavity augments the auto-intoxication already 
present. 

The specific cause of pyorrhea alveolaris and den talis has 
apparently been placed upon endamebae by M. F. Barrett 
and Allen J. Smith. 

The writer recommends that in all pellagrins with the 
slightest indication of buccal infection, a \ -grain injec- 
tion of erne tin be given every day for six days. After two 
weeks have elapsed this should be repeated; and, if the 
mouth remains sore or unclean in appearance, the "six-day 
treatment" with emetin may be repeated four or five times. 

It is well, also, in addition to any other methods of treat- 
ing the sore mouth, to have the patient wash his mouth 
twice daily with a solution of 3 drops of fluidextract of 
ipecac in a half-glass of water. This does not eliminate 
the necessity for appropriate dental attention. 

The importance of obtaining a hygienic state of the 
mouth, the main portal of entry to the body, has been un- 
derestimated, and the medical attendant will find the time 
and trouble expended in putting this cavity in order well 
spent. 

Sleeping in the open air, as in tuberculosis, has been 
advocated by some, and has its advantages when properly 



200 PELLAGRA 

followed. An abundance of fresh air is in order at any stage 
of the disease. 

Regular hours for sleep, for rest or recreation, or for any 
occupation, no matter how light, must be scrupulously 
kept; for the slightest form of dissipation will react inju- 
riously on the sensitive alimentary tract and unstrung 
nerves. 

As in the dietetic regimen, each individual case will 
have to be managed on its merits, regulating the habits in 
accordance with the financial ability, temperamental status, 
or varying phases of the illness. 

Hydrotherapeutic Treatment. — The effects of hydro- 
therapy in pellagra have in many instances been so bene- 
ficial that, whenever practicable, some forms should be 
invoked. 

Hot or cold baths, simple and medicated, douching, 
packs, moist or dry rubs, accompanied by special massage, 
have proved their worth, bringing about increased oxida- 
tion of the tissues, more rapid elimination, greater metabolic 
activity, sharpened appetite, improved digestion and assim- 
ilation, and a noticeable tonic effect on the whole living 
organism. 

Among the indications for well-directed hydrotherapy 
are vertigo, stuporous states, parasthesias, tremors, rigid- 
ity of the limbs, insomnia, constipation (occasionally diar- 
rhea), and other neurasthenic manifestations, numerous as 
they generally are. 

Either hot or cold baths may be employed, the hot being 
more grateful to the extremes of life or the feeble. It 
has been ascertained that practically the same tissue changes 
follow a hot bath as a cold one, being caused by an effect on 



DIFFERENT METHODS OF TREATMENT 201 

the innervation or the muscles; in fact, all combustion 
processes in the body are referable to the muscles. A 
simple hot-air bath may have little effect, but a series of 
hot-air or hot-water baths increase nitrogen eHrnination, 
urea elimination keeping pace with the excretion of nitro- 
gen, and uric acid is also excreted in greater quantity. 

" Elaborate studies of these metabolic changes have 
been made by many observers, and in connection with 
ordinary hydriatic procedures, the half-bath, the Scotch 
douches, etc. It is interesting to note that Hippocrates 
states that the temperature elevation which occurs in 
connection with most acute infectious diseases is, within 
limits, remedial in purpose and effect. It apparently fol- 
lows that temperature elevation baths may be beneficial 
in aiding resistance to infection, especially when followed 
by a short cold bath, by favoring the production of alexins 
and antitoxins. It seems to us, however, that cold baths 
are better, practically, in the infectious fevers — witness the 
brilliant results attained by the Brand treatment of ty- 
phoid fever. That baths of such obviously different char- 
acter lead to very nearly the same physiologic results is 
one of the seeming paradoxes of hydrotherapy. This 
is recognized in practice, for, if patients do not react 
well to the cold baths, it is well to give a bath at no° or 

112° F. 

" Dr. Simon Baruch explains this seeming paradox by 
the physiologic fact that both heat and cold are thermic 
irritants, which, briefly applied, excite the peripheral sen- 
sory terminals and thus stimulate. The secondary effects 
differ decidedly if the application be prolonged " (Hins- 
dale). 



202 PELLAGRA 

A few specific directions for some of the baths will be 
given, taken in the main from Dr. Hinsdale's excellent 
work on hydrotherapy. 

The Warm Full Bath. — A large tub is rilled three-quarters 
full of water at 95 ° to 100 ° F., in which the patient is fully 
immersed, first having his head covered with a wet cloth in 
cold water. The room should be at a temperature of 
about 80 ° F., and means should be at hand for maintaining 
the water at its initial degree of heat, for this bath is usually 
prolonged to ten, fifteen, or twenty minutes or more, as 
required. Indeed, the duration of a bath has been extended 
by Hebra and others to days and even months, the patients, 
some of whom suffered from extensive burns, bed-sores, 
pemphigus, and other skin diseases, existing in the contin- 
uous bath for remarkably long periods. If continued for 
several hours, the patient may sleep in the bath, but he 
naturally requires constant attendance, special lifting 
apparatus, and electric and other appliances for maintain- 
ing a constant temperature. For dermatologic purposes 
ioo° F. is considered best. Mutton suet, lanolin, or pe- 
trolatum applied thoroughly to the skin protects it from 
puckering or peeling. 

Hot baths of greater or less duration, as described above, 
can exert a most helpful effect in some of the neurasthenic 
pellagrous patients where all other methods have seemed 
unavailing, and the physician is importuned to redouble 
his efforts, in the slender hope that some good may arise. 

The Cold Bath. — For fairly vigorous persons the best time 
for the cold bath is before breakfast. Weak or delicate 
persons may take it in the forenoon. Chill, languor, or 
drowsiness coming on after cold baths are contraindications 



DIFFERENT METHODS OF TREATMENT 203 

to their continuance; tepid baths are then to be substituted. 
Vigorous friction should always follow the use of cold. 

The water of a cold bath is usually drawn in a tub from 
the public supply, and varies, according to the season, from 
40 ° to 70 F. The cold bath is the favorite of the Anglo- 
Saxon race and in those who need to get up a reaction; for 
the drowsy pellagrins of the " florid type " or for the robust 
who tend to a high temperature the plain cold bath is 
often most grateful. 

Salt Bath or Rub. — This may be given as follows: The 
patient is placed in a tub of warm water, the temperature 
of which may be practically judged by the hand, which 
should be able to bear it with comfort. The salt should 
be of a fine quality and should not contain coarse particles. 
A good kitchen or cooking salt answers all requirements. 
The attendant, having stood the patient up in the tub, 
wets his hands and dips up a handful of the salt. With it 
he thoroughly and firmly, but not roughly, rubs the body 
all over for some fifteen or twenty minutes. The patient 
is then made to lie down in the water, the salt is washed off, 
and after a few minutes a cold douche is given. He is then 
put to bed at rest for a time. This may be done three or 
more times weekly. 

Where a powerful effect on the nervous system is desired 
the Scotch douche, which is an alternating douche of hot 
and cold water or steam and cold water, may be used. 
The facilities for these special forms of hydrotherapy are 
found only in properly fitted institutions, and their appli- 
cation should be entrusted only to those who are trained 
to scientifically use them, or harm might result. 

The use of rectal douches for proctitis, tenesmus, or over- 



204 PELLAGRA 

loaded rectum, or irrigation with the recurrent rectal tube 
(Kemp's) for sedative or cleansing purposes, have their 
useful place, and do not vary materially in their indica- 
tions or application in similar bowel inflammations from 
other causes than pellagra. 

The same may be said of vaginal douches. 

At all times the patient should be urged to drink a suffi- 
ciency of water, so that the blood-pressure may be main- 
tained, the fecal current well supplied with moisture, the 
kidneys freely flushed, and, by the solvent power of the 
water, the eliminative functions be enabled to dispose of 
a maximum of toxins. 

The question of gastric lavage in pellagra is a somewhat 
complicated one. As a routine measure it holds no place. 
The gastric disturbance is not primary with the stomach 
any more than it is with the skin, and to attempt to con- 
trol the digestive manifestations by lavage would neces- 
sarily prove disappointing. 

Where catarrhal gastritis complicates the trouble, or a 
deficient motor function of the stomach or a stenosis of the 
pylorus permits an undue damming of the stomach-contents, 
lavage at not too frequent intervals will afford some relief . 

When this procedure is employed, it is well to use first 
plain warm water, then the medicated fluid, then follow 
up with plain water. 

Should the lavage be followed by colicky pains or should 
the tube irritate the fauces, it is wiser to either discontinue 
it or use it at infrequent intervals. 

Medicinal Treatment. — The application of medicinal 
remedies in pellagra is, in the opinion of the writer, fruit- 
ful of much benefit. Many of the most distressing symp- 



DIFFERENT METHODS OF TREATMENT 205 

toms can be either relieved or mitigated, and just because 
a positive specific has not been found is no reason why a 
therapeutic pessimism should be allowed to dampen the 
ardor of the physician. Therapeutic pessimism is the 
inevitable refuge of the weakling, and if the medical at- 
tendant is imbued with that spirit he should hesitate in 
treating pellagra. 

For the sore mouth and tongue an application of nitrate 
of silver (20 grains to the ounce of water) daily or on al- 
ternate days is recommended. A mouth- wash of boro- 
glycerin (25 per cent.), or half -strength liquor alkalinus 
antisepticus, or a combination of chlorate of potash and 
glycerin, with rose-water as a vehicle, will generally prove 
satisfactory. For the aphthous ulcers, ofttimes so pain- 
ful, gentle " touching " with half -strength aromatic sul- 
phuric acid once daily, or a liberal application of a mild 
solution of salicylic acid in glycerin and alcohol, will be 
sufficient. 

The emetin treatment, as previously described, will in 
many instances promptly abate the sore mouth. 

For the salivation give ^fo- grain atropin every four 
hours till the dribbling ceases; then stop, for the continu- 
ance of the atropin would cause uncomfortable dryness of 
the mouth and fauces. 

Should the interior of the buccal cavity and fauces be- 
come dry and uncomfortable, a frequent spraying with 
liquid albolene, to which a little menthol has been added, 
will prove most grateful. 

As a constitutional treatment the writer recommends the 
following, which has been evolved from his own experience, 
augmented by suggestions from others in whom he has 
confidence. 



206 PELLAGRA 

At present the writer employs for hypodermic use 16- 
minim ampoules of iron arsenite solution, and ampoules 
of sodium cacodylate, i c.c, each ampoule containing f 
grain of the drug. One of each is injected on alternate 
days, injecting them under careful aseptic precautions. 
This injection on each day, but alternating the drug, is 
kept up for two or three weeks, then the injection is given 
every second day, still alternating the ampoules, for two 
or three weeks longer. After that the injections are given 
only about once a week (still alternating), as long as it is 
practicable or considered advisable. 

Internally it is recommended that a combination of Fow- 
ler's solution and a saturated solution of potassium iodid 
be given, beginning in 5-drop doses and increasing 1 drop 
daily until the physiologic limit is reached. Generally 
the puffiness under the eyes appears when about 25 to 30 
drops are being taken. When this appears, the drops should 
be discontinued for two days, and started at the minimal 
dose of 5 drops, increasing gradually as before. Some can 
take larger doses without discomfort than others, but it 
answers no good purpose to push it after the physiologic 
limit has been reached. Occasionally the patient, on ac- 
count of excessive irritability of the alimentary tract, will 
prove intolerant of arsenic internally. Should this be 
apparent, the saturated solution of potassium iodid alone 
may be pushed, given in a little sweet milk. 

This is the formula: 

I£. Liquor potassii arsenitis 3 drams. 

Saturated solution kalium iodid 5 " 

The number of patients who could not tolerate this 
formula have been extremely few. 



DIFFERENT METHODS OF TREATMENT 207 

After the active symptoms of pellagra have abated, and 
iron does not seem to be indicated, this formula may be kept 
up almost indefinitely in 6- or 8-drop doses three times 
daily. 

For the frequent diarrhea, bismuth-betanaphtol and 
resorcin, given with milk of bismuth as a vehicle, has 
generally been sufficient. This failing, there may be given 
tannigen, protan, or heavy doses of bismuth subgallate. 
As a last resort, powdered opium or tincture of opium may 
be used, but opium, as an intestinal astringent in pellagra, 
has its disadvantages, as it seriously interferes with the 
much-needed elimination. The writer prefers 10-grain 
doses of tannigen, given as indicated by the severity of the 
diarrhea. 

When there is a paucity or absence of free hydrochloric 
acid in the gastric secretions, 10 or 12 drops (not more) 
of dilute hydrochloric acid, well diluted and given thirty 
minutes after meals, will often greatly aid digestion and 
lessen the " heavy feeling " so much complained of. 

For the anorexia, tincture of nux vomica, condurango, 
calumba or quassia, with compound tincture of gentian or 
cinchona as a vehicle, will often sharpen an indifferent 
appetite if given a short time before meal time. 

In anemic or cachectic conditions the various ferrugin- 
ous preparations are indicated, as well as cod-liver oil, 
olive oil, or official preparations of the hypophosphites. 

A malarial complication, often present, either openly or 
latently, will require the addition of quinin, which may be 
administered in the most eligible form. 

Constipation, when present, may be controlled by castor 
oil or enemas, drastic cathartics being inadmissible. In 



208 PELLAGRA 

these infrequent cases of constipation in pellagra an in- 
jection of 2 to 4 ounces of cotton-seed or olive oil, intro- 
duced into the rectum on retiring and kept in all night, 
will generally produce a soft, unirritating and effectual 
evacuation of the bowels the next morning. 

The writer is also employing, with good results, the liquid 
paraffin, given as required — generally a tablespoonful night 
and morning. 

Mention might also be made of phenolphthalein, which, in 
i- or 2 -grain doses at night, is followed by satisfactory 
movements. 

At present, reports of the use of hexamethylenamin are 
being sent in with some frequency, and it may be found that 
in this preparation a useful agent has been found. Its 
physiologic elimination in the urine, bile, cerebrospinal 
fluid, and other fluids of the body may enable this drug to 
exercise an antitoxic effect. 

Ichthyol, too, is recommended by some. 

The symptoms of nervous irritation, expressed by burn- 
ing hands, feet, or mouth, will often tax to the uttermost the 
resources of the physician. These may be combated by 
compresses saturated with a mild solution of bichlorid of 
mercury, ice cold, and applied at frequent intervals; by 
baths in hot mustard water or very slightly mentholated 
applications of liquid albolene. In occasional instances 
this burning becomes so intolerable as to require an ano- 
dyne. 

The aches and shooting pains may often be alleviated by 
5-grain doses of acetylsalicylic acid, given four times daily. 
This sometimes burns the stomach, but not often. Phe- 
nacetin, to which is added a small amount of citrate of 



DIFFERENT METHODS OF TREATMENT 209 

caffein, may also be employed for the headache or the 
different neuralgias. 

Massage in some instances affords decided relief in mus- 
cular pains, and the rubbing in of a gently stimulating lin- 
iment is not amiss. 

The erythema, being a secondary symptom, should re- 
ceive only palliative treatment. Too many applications 
tend to irritate more than soothe, and too many ointments 
can sometimes transform a dry erythema into a moist one, 
which is far from being desirable. 

While the hands are red and hot, a lotion, as suggested 
by Dr. Babcock, is serviceable: 

Pulv. calamine 4 drams. 

Pulv. zinc oxid 3 " 

Rose-water 2 ounces. 

Lime-water, to make 1 pint. 

This may be applied ad libitum. 

After desquamation begins, there are several mild oint- 
ments available. 

The writer has used with satisfaction the 5 per cent, 
boric acid ointment. Dr. Babcock recommends: 

Pulv. calamine i dram. 

Zinc oxid § " 

Olive oil 1 " 

Lanolin, to make 1 ounce. 

Gentle cleansing of the scales or crusts, after having 
been softened with some oily substance, will promote the 
comfort of the patient. 

When other applications to sore and crusted skin have 
failed, the writer recommends the scarlet-red ointment 
(Heilkraft). This may be applied once or twice daily and 
is quite efficacious. An objection to its use is the stain it 
produces upon any article it touches. 

14 



2IO PELLAGRA 

When the erythema attacks the eyelids and sympathetic 
conjunctivitis ensues, a weak solution of argyrol dropped 
in the eyes will generally prove adequate for relief. 

For great exhaustion, the intravenous injection of saline 
solution (300 ex.), every day or alternate day, is suggested. 

For the mental and psychic symptoms, appearing as 
they do in such multitudinous forms, only general sugges- 
tions can be made. To treat these manifestations by any 
rule-of-thumb would be irrational and fruitless. 

Sleeplessness may be combated by chloral, trional, or 
veronal. By the addition of phenacetin to veronal the 
good effect is augmented and disagreeable after-effects 
prevented. Morphin or codein for insomnia is to be dep- 
recated. 

Tincture of opium or powdered opium are useful for the 
melancholia, but they must be aided by isolation and rest. 

Dr. Hansell Crenshaw believes that the degenerative 
changes in the cord and brain are best resisted by iodids, 
mercurials, and arsenic. In short, he believes that the rav- 
ages of pellagra upon the nervous tissues are similar to the 
ravages of syphilis upon these tissues, and that the treat- 
ment should be parallel. His explanation of the apparent 
failure of salvarsan to aid pellagra is based on the hypoth- 
esis that the drug has not been adjusted to pellagra by 
606 careful experiments, as it has in syphilis. 

When the mental symptoms deepen into the more pro- 
nounced forms of melancholia or lapse into dementia or 
amentia, the patient should be put in an institution for 
the mentally sick. These unfortunate invalids are subject 
to so many varying moods, suicidal and otherwise, that it 
is almost impracticable to properly and safely care for them 
at home. 



DIFFERENT METHODS OF TREATMENT 211 

While many of the pellagrous neuroses and psychoses 
are the result of degenerative changes, where scar tissue 
impedes and cuts off conduction, still, in many instances, 
if the treatment is persisted in with a spirit of optimism, 
unexpected improvement may brighten a gloomy prognosis 
and light may emerge from sad obscurity. 

We are not as yet thoroughly conversant with the influ- 
ences of the mind over metabolic processes upward or down- 
ward, and, while due caution should always be observed in 
any predictions, no one man nor set of men are privileged to 
abrogate the Junctions of a supreme court by asserting that 
pellagra is an incurable disease, and that medical treatment 
is valueless. 

Climatic. — Pellagra, being in the main a disease of hot 
weather, it has been found in nearly every instance that a 
sojourn to a cooler climate was beneficial. Cold climates, 
or those where the winters are long and the summers corres- 
pondingly short, have never seemed to furnish a congenial 
soil for the spread of pellagra. 

Goldberger believes that a change in climate is valuable 
only in proportion to the degree and character of the change 
of diet it involves. With this assumption the writer does 
not agree. 

Pellagrins, unless too far advanced, get better with cold 
weather, and only the practically hopeless cases go on to 
exhaustion and death in the winter season. 

Many, from financial or other reasons, cannot seek a cool 
climate, but all that can should avail themselves of this aid. 
In this country, in order to reach a cool climate in the 
summer time, a high altitude must be sought, and careful 
advice must be given regarding the influence of altitude 
on the vital organs. 



212 PELLAGRA 

It has been the experience of the writer and others that 
the benefit to the pellagrous symptoms nearly always ex- 
ceeds the possible danger of high altitude, and, unless there 
are strong reasons, this consideration should not prevent 
climatic change. 

In order to reap the full benefits from this change the 
writer believes that the pellagrin should avoid hot weather 
for ten or twelve months after all symptoms have disap- 
peared. 

Where it is not practicable to reach an actually cool 
climate, a lesser change is sometimes beneficial, but the 
change should always be to a higher latitude and altitude 
— never a lower one. 

This, in bo'th a general and specific manner, covers the 
treatment of pellagra. Much of it has, of necessity, been 
rather general, but the writer feels that the therapeutic 
field, according to the present knowledge of the disease, 
has been fairly covered. 

Our pellagrous charges expect an honest effort to be ex- 
pended in their behalf; they demand it, and we, as healers 
of the sick, have no right to consign them to the "slough 
of despond," nor have we the moral claim to banish this 
disease to the limbo of "incurable affections." 

Let us, therefore, give our suffering and disconsolate 
pellagrins the full benefit of our knowledge as we acquire 
it, hoping in the meanwhile that the discovery of a specific 
treatment may be attained in the near future. 



CHAPTER IX 
THE PROPHYLAXIS OF PELLAGRA 

This important chapter in the discussion of pellagra un- 
fortunately must be approached from a theoretic standpoint, 
for, until we have positive information as to etiology, we 
are necessarily dealing in assumptions, not in proved facts. 

One of the first questions that arises is concerning the 
communicability of pellagra, for on that hinges much of the 
prophylaxis. 

The consensus of opinion at present is against the possi- 
bility of this disease being either contagious or infectious, 
but toxicochemical, and, as such, it cannot be transmitted 
from one individual to another. 

As early as the middle of the last century Roussel 
wrote: " It can be said of the contagion of pellagra that it 
is a question fully determined — pellagra is not contagious." 

To admit this, or to attribute the spread of pellagra to 
a contagion or an infection, would bring up the questions of 
isolation and quarantine, serious questions to individuals 
and communities, unless supported by strong reasons. 

Italy has suffered and so have other European countries, 
some of whom have apparently solved the problem, but 
it was solved according to the zeist doctrines. 

Apart from the ordinary precautions, hygienic and die- 
tetic, already considered, the prophylaxis will be covered by 
an account of the methods of prevention in other countries, 

213 



2i 4 PELLAGRA 

that, from their long and trying experiences, we may learn 
and perhaps utilize some of their methods. 

Joseph II., of Austria, was the first sovereign to concern 
himself with pellagra, giving those who sought to prevent 
and treat it all the aid in his power. 

The first serious attempt in Italy to deal with the prob- 
lem was in 1879, ten years after Lombroso's fame was es- 
tablished. 

Much of the following is extracted from the consular 
report rendered by the late Bayard Cutting, Jr., and pub- 
lished by the United States Government. 

In the year above mentioned a census was taken of the 
pellagrous patients in Italy, and as a result of the census 
a bill was introduced for the regulation of corn cultivation 
and importation, and the establishment of desiccating 
machines. The bill failed, and the only immediate result 
of the census was an annual grant of 36,000 lire from the 
Government toward the relief of pellagra — about 6 cents 
for each patient. This amount was raised at a later date, 
until it amounted to 70,000 lire in 1889; and under the law 
of 1902, 100,000 lire are contributed annually for the pre- 
vention and cure of pellagra, and as much more for the in- 
troduction of improved methods of agriculture. The census 
of 1879 was an epoch-making event. It brought home to 
the people, as a whole, the gravity of the situation, and it 
stimulated the various provincial governments to act in- 
dependently. Many provinces appointed pellagrologic 
commissions, took censuses, and founded hospitals or 
" local sanitariums. " From 1879 to 1903 was a period of 
local and provincial activity. The conclusions of doctors 
were tested on a small scale, and the way prepared for gen- 



THE PROPHYLAXIS OF PELLAGRA 215 

eral legislation. Meanwhile, in 1895, the Crispi adminis- 
tration issued an ordinance forbidding the importation of 
spoiled corn, and providing for inspection at chief ports. 
In 1902 the " law for the prevention and cure of pellagra " 
was passed, and in the following year was issued the regu- 
lations for the enforcement of the law. Since that time 
five years have elapsed, and already pellagra may be said 
to be a doomed disease. The statistics, so hard to inter- 
pret as regards particular details, bear unmistakable testi- 
mony to a general decline in the disease under the operation 
of the law. 

The main provisions of the law and regulations are as 
follows : 

I. Absolute prohibition of the importation, sale, holding 
for sale, or grinding of spoiled corn or products of corn 
destined for human food. If the corn is destined to feed 
animals or to be used for other purposes, it is admitted 
only by special permit of the prefect. 

II. Obligation upon all communes to report cases of 
pellagra. A commune with several cases is declared pel- 
lagrous, and falls under the following provisions: 

(1) Government inspection of all corn dried, stored, and 
consumed in the commune. 

(2) Obligation on the part of commune and province to 
establish public desiccating plants, to provide curative 
nourishment for all patients, to provide patients and their 
families with free salt, and to treat severe cases in special 
institutions. 

III. Establishment of pellagrologic commissions in all 
provinces affected with the disease. 

IV. Assignment of a government grant of 200,000 lire 



216 PELLAGRA 

annually, and obligation upon the provinces and communes 
to defray, in equal portions, the expenses entailed by the 
act. 

This is the charter under which the struggle against 
pellagra is now being carried on. It is proposed to examine 
the several dispositions of the act, then to give some details 
in regard to certain provinces which Mr. Cutting was able 
to investigate in person, and, finally, to append such other 
data as will be of the most profit to those interested in the 
fight being waged by Italy against this scourge. 

It will not be necessary or appropriate to enter into the 
public curative measures, but the well-ordered prophylactic 
measures will be described. Those chiefly to be noted are: 
The testing of corn and flour brought in at the frontier, 
or offered for sale or brought to the mill, the exchange of 
bad corn for good, desiccating plants, cheap co-operative 
kitchens, the improvement of agricultural methods, and 
the instruction of the people as to the danger of bad corn. 

The first preventive measures are to protect the peasant 
from imported spoiled corn. He must be taught to grow 
corn that will ripen, to harvest it ripe, to dry and store it 
properly, and to see that it does not become spoiled in 
milling. 

Such cautions do not apply to Italy alone, but might be 
suitably inaugurated in the United States. 

Prohibition of Spoiled Corn. — As far as regards corn im- 
ported from abroad, the provisions of the law of 1902 seem 
adequate in most respects. All suspicious cargoes are 
tested by experts, and, if the condition is not satisfactory, 
the corn must be sent to a distillery or else be denatured. 
Spoiled corn can be detected in a number of ways. Such 



THE PROPHYLAXIS OF PELLAGRA 217 

outward signs as mildew or the smell of mold are, of course, 
conclusive, but they can be removed by drying in the sun; 
their absence, therefore, does not prove the soundness of 
the corn. But the consumer should be warned against any 
corn that is covered with dust, that is damp to the touch, 
or that gives forth any smell of mold when warmed in the 
palm of the hand. He should be on his guard against corn 
of a pale color with a dull surface. 

There are several chemical tests for distinguishing sound 
from moldy corn. The first test is the proportion of 
ashes. It is said that no sound corn contains more than 
4 per cent, of ashes. This point is doubtful, and the test 
requires an accurate apparatus, and is unsuitable for gen- 
eral use in inspecting imported corn. The second test 
is that of Gosio, with perchlorid of iron. Corn-flour which 
has been kept in double its volume of alcohol (at 80 degrees) 
for several days, being frequently shaken meanwhile, and 
exposed to the sun or to heat, is tested, after the alcohol has 
been filtered and evaporated away, in a bath of perchlorid 
of iron solution. The reaction varies in color, from a 
dark green to a violet blue, according to the soundness of 
the corn. This test, though one of the best, is not entirely 
sufficient. It should be supplemented by the test of acid- 
ity; since moldy corn is always more acid than sound. 

The biologic test of fruitfulness is one of the best, since 
spoiled corn is certain to lose much of its germinating qual- 
ity. The test is easy to apply, but is, of course, ineffective 
for corn which has been desiccated. There is also the test 
of poisonous content by the actual inoculation of mice. 

In theory, possibly all of these tests are required, but 
for practical purposes it may be said that corn which ap- 



2i8 PELLAGRA 

pears perfectly sound, and which does not react to the 
perchlorid test, is pretty sure to be harmless. In doubtful 
cases the germination and acidity test can be employed. 

Inspection of corn at the frontiers is comparatively easy, 
but at the mills or in the markets, and especially in the 
shape of flour, it is practically impossible. The flour 
problem is entirely beyond the control of any government; 
the only hope of its solution would lie in government or 
municipal ownership of all mills. This proposal is eagerly 
supported by those interested in the pellagra question; it 
is certainly more practical than any plan for diminishing 
the corn area in Italy or for prohibiting entirely the im- 
portation of corn. Whether it is likely to be adopted is as 
yet uncertain. Meanwhile, and so long as milling is a 
private industry, the effort must be made to send only sound 
corn to the mill. 

Every province of Italy has a commission for the en- 
couragement of improved methods of agriculture. These 
" moving chairs " — or, as we might call them, farmers' in- 
stitutes — are active institutions which have contributed 
notably to Italy's great agricultural progress during the 
last decade. 

These farmers' institutions are now in successful opera- 
tion in many states in our country, augmented in some in- 
stances by trains, educational in their scope, which go from 
place to place teaching the doctrine of scientific farming. 
" Corn shows " also are being held, where the principles 
of raising more and better grain are inculcated to the masses 
in an attractive manner. 

In solving the pellagra problem they co-operate very 
usefully with the provincial pellagrologic commission. 



THE PROPHYLAXIS OF PELLAGRA 219 

The pellagrologist wishes to get rid of the quarantino corn ; 
the cattedre ambulanti show the farmer a better crop than 
quarantino, teach him how to grow it, and prove to him by 
actual experiments that the new crop is more profitable than 
the old. The rapid disappearance of quarantino in Lom- 
bardy and Venetia is largely the result of intelligent mission- 
ary work by these agricultural commissions. Instead of 
quarantino the peasant is taught to plant the niathilde, 
millet, mustard, or some kind of forage. There is no doubt 
that all of these crops are more profitable, as a second crop, 
than quarantino. 

It is no small triumph to have convinced the Italian 
peasant of the fact, and to have induced him to abandon a 
traditional crop for one with which he was not familiar. 
Next to the inspection of foreign corn, the diminution in 
the supply of quarantino has probably accounted more 
than any other factor for the encouraging decrease of 
pellagra during the last five years. 

Desiccating Plants. — Artificial drying of Indian corn 
was practically unknown in Italy until within a few years. 
Such corn as was dried at all was merely hung in the open 
air, on frames, at the sides of the houses. Most of the corn 
was stored as soon as gathered and in any storing place 
that was available, without regard to ventilation or clean- 
liness. If Italy is the home of pellagra, while Mexico and 
Burgundy are entirely free from the scourge, the difference 
may be due simply to the fact that in Mexico and Burgundy 
corn is fired almost as soon as harvested. Artificial desic- 
cation is the most important of all prophylactic measures 
against pellagra. It has objections, however, to encounter 
from the farmers. The corn loses weight, they say. This 



220 PELLAGRA 

is true, but the weight lost from decay is far greater. It 
will not germinate. This is true likewise if the desicca- 
tion is not properly performed; but the best desiccators 
leave the corn with all its natural properties unimpaired. 
It is expensive. Not so expensive, on the whole, as the 
out-door frames. The best desiccator yet contrived, that 
of Pietro Cattaneo, dries no pounds of corn with a fuel 
consumption of one cent. Nevertheless, in order to re- 
move as far as possible the objection of expense, the law 
of 1902 provides that every family may dry, at the public 
desiccator free of charge, so much corn as is required for 
the household needs. Further use of the desiccator must 
be paid for, but at rates which allow nothing for profit. 

Desiccators are of two types — fixed and portable. The 
portable type has the great advantage of saving the cost 
of transportation of the corn. It can be carried in sec- 
tions and set up in the middle of a corn belt. It is cheap 
enough to be within the means of the poorer classes. The 
fixed type, however, is infinitely preferable. The air is 
kept at an even temperature and circulates equally in all 
parts of the machine; thus none of the corn is spoiled or 
deprived of any of its properties. Air heated by a furnace 
is forced into a chamber of seven stories. Each story is a 
revolving wire tray, containing about 1400 pounds of corn. 
The top tray is filled from above. After a certain time its 
contents are emptied by pressing a lever into the tray below 
in such a way that they are thoroughly remixed. The corn 
thus passes gradually to the bottom tray, whence it goes to 
a receptacle where it is cooled by means of a ventilator, 
and thence out of the machine by an inclined plane. The 
first tray-load of corn takes seven hours to pass through the 



THE PROPHYLAXIS OF PELLAGRA 221 

machine; after that 1400 pounds come out each hour. 
The cost of the machine is about $540, and the power re- 
quired to run it about 2\ horse-power. Larger machines 
of the same kind, costing about $1840, have a daily capacity 
of 88,000 pounds, and require an engine of 8 horse-power. 
In the Cattaneo desiccator the air is forced through the 
trays in both an upward and downward direction; the air 
which has absorbed dampness from the corn is replaced 
constantly by dry air; the temperature is kept low (about 
104 ° F.), with economy of fuel and without risk of injuring 
the corn; and the mechanism is so simple that the machine 
can be handled by any laborer of ordinary intelligence. 

The best of the movable desiccators is probably the Boltri, 
which costs about $112, but, on account of the danger of 
destroying the germinating power of the corn, it is best 
always, if possible, to employ the more expensive machines. 

Desiccation, if applied to moldy corn, will remove the 
moldy appearance, but in order to kill the poison germ a 
temperature not merely uneconomical, but actually de- 
structive of the grain, would be required. It is, therefore, 
of the utmost importance to prevent the use of the public 
desiccator for corn which is even a little spoiled. 

Public Storehouses. — Another article in the law of 1902 
gives power to prefects to order the authorities of any pel- 
lagrous communes to found a municipal storehouse for the 
use of such inhabitants as do not possess sanitary houses; 
yet the insanitary conditions under which corn is stored in 
the houses of peasants have long been recognized as a 
potent producer of pellagra. 

Ceresoli recently said: " The greatest injury to this food 
is inflicted by those who are to use it. The corn is kept al- 



222 PELLAGRA 

most always in the darkest corners of the rooms, against 
damp walls, surrounded by dirty clothes, exposed to all 
human emanations, and to all those foreign substances 
introduced by animals and insects. . . . Pellagra will not 
cease until the worst houses are destroyed, the rust cleaned, 
and the corn stored in a place apart." 

There is no doubt that the public storehouses will come, 
but for the present the cost of construction and mainte- 
nance and the expense of transportation are beyond the 
means of the Italian communes. 

Rural Bakeries. — The effort to eliminate from the diet of 
peasants bread made of Indian corn and to substitute 
wheaten bread has taken shape in the establishment of 
bakeries, where good wheaten bread is furnished at cost. 
The institution is comparatively new. In 1904 there were 
only 77 such bakeries, and in 1905, 89; but in 1906 the 
number had risen to 584, and in 1907, to 591. There is 
no question that corn-bread will soon cease to be a common 
article of food in northern Italy, and the elimination of 
corn-bread will mean, if nothing else, added variety in the 
diet of agricultural classes. 

Corn Exchanges. — The idea of an exchange where moldy 
corn could be exchanged for good is due to Prof. Ceresoli, 
who carried it into execution at Bagnolo Mella. The peas- 
ants bring their corn, good or bad, and receive in exchange 
a lesser amount of perfect flour, deduction being made for 
the cost of milling and for any defects in the corn delivered. 
The cost of the operation, which was met at Magnolo Mella 
by charitable gifts, amounted to 23 cents per hundred 
pounds of corn. At this place the exchange was popular 
with the community; it meets with the approval of all stu- 



THE PROPHYLAXIS OF PELLAGRA 223 

dents of pellagra, and it is not very expensive in the com- 
parison with the immense benefit conferred. Neverthe- 
less, the scheme has not been successful. In 1904 there were 
four exchanges, and 439 quintals of corn exchanged; in 1905 
the figures rose to seven and 1145, only to fall in 1906 to 
five and 674, and in 1907 to four and 292, for the exchange 
will never give more than five kegs at a time, and usually 
gives only one keg, in order that the flour may not have time 
to spoil at home. 

The following may be considered the general conclusions 
of those who have made this fight as to the lessons learned 
and the results obtained. The list of preventive measures 
against pellagra is by no means exhausted, and many have 
been suggested which have not been adopted. In general, 
the object is to get at the children; to prevent pellagrous 
mothers from nursing their babies, or, if this cannot be 
prevented, to see that the mothers are well fed; to treat a 
child the moment he or she shows the slightest symptoms of 
pellagra, and to send the little patient away from the sur- 
roundings where the pellagra has been acquired. There 
are authorities, however, and of the highest rank, who see 
no remedy for pellagra short of the total elimination of corn 
as human food. Some would forbid its importation; others, 
who have noticed that pellagra increases when corn is dear, 
would throw open the ports of the country by the removal 
of the protective duty. Still others wish for the prohibition 
of the cultivation of certain kinds of corn, or of all corn in 
localities where it is not " economically profitable." So 
long as national habits remain what they are, so long will 
there be a demand for a certain amount of corn. If im- 
portation is difficult, the home crop will increase, and 



224 PELLAGRA 

vice versa. It is not by legislative restrictions, but through 
changes in a national taste, that corn consumption can be 
diminished. Education of the people to the dangers of 
bad corn, their awakening to the possibility and pleasantness 
of a varied diet — there is the remedy. Much is being done 
to educate the people. The industrious Permanent Com- 
mittee of the Interprovincial League against Pellagra edit 
a magazine, the Rivista Pellagrological Italiana, devoted 
to the struggle against the disease. Popular pamphlets 
are distributed in great numbers; popular lectures are 
held everywhere; big colored lithographs, representing the 
healthy laborer fed on sound corn and the pellagrous laborer 
fed on spoiled or moldy corn, hang on the walls of public 
lecture halls; and the pellagrologic and agricultural com- 
missions of the different provinces multiply instructions 
by both precept and example. The results vary with the 
various districts, but they are encouraging on the whole, 
and they coincide with a marked rise in general prosperity. 
The laborer who wants to eat something else besides corn 
can do so to-day as he never could before. Great numbers 
of the rural population are employed in factories, where they 
obtain a varied diet. The effect of industrial life is clearly 
shown in the numerous decrease of pellagrous cases be- 
tween the ages of twenty and thirty; many Italians spend 
the summers in foreign countries as laborers; when they 
return in the winter, it is not only with a stock of money 
for the family, but also with a stock of experience. They 
no longer care to live on polenta only. Their wives and 
daughters who have stayed at home may go on with 
the old fare, but the men require mixed diet. It is in- 
dustrialism and temporary emigration, far more than the 



THE PROPHYLAXIS OF PELLAGRA 225 

habit of dining occasionally at a trattoria, which accounts 
for the predominance of women over men among pella- 
grins of the vigorous age. If the predominance is not still 
more marked, it is due to a contrary tendency among 
those to stay at home and work in the fields. Among 
these classes the men suffer most; possibly because they 
work harder, possibly because they eat more polenta, or 
for both reasons. One thing, at any rate, is plain — that 
even without government activity and private aid pellagra 
would be diminishing in Italy to-day. The consumption 
of meat is increasing rapidly; the people are living better, 
the farm laborer gets higher wages, and, if he accepts a 
part of his wages in kind, he no longer allows the landlord 
to pay him in moldy corn. Thus, many causes unite to 
aid the fight against pellagra, and for this reason it is hard 
to say how much, if any, of the progress is due to legisla- 
tive enactment. 

If we leave statistics and listen to the opinions of experts, 
we shall reach the conclusion that pellagra in Italy is de- 
creasing notably both in numbers and in intensity, but that 
it is extending its area. The causes of the decrease have 
been, in the main, the improved conditions of the laboring 
classes through the diversification of industries, temporary 
emigration, scientific agriculture, and improved wage con- 
tracts; but a part, at least, of the progress is directly at- 
tributable to direct measures of prevention and cure. 
■ Pellagra hospitals, sanitary stations, and food distribu- 
tion have lengthened the life of the pellagrins and averted 
the worst form of the disease. Such preventive measures 
as desiccating plants and rural kitchens have aided in pro- 
tecting the peasantry from its scourge. But, above all, 

15 



226 PELLAGRA 

the prohibition of spoiled corn has had an immense effect 
upon the public health. What is needed is an extension 
of the government control to mills and the milling industry. 
And, while all ideas of prohibiting corn, either as a crop or 
as an article of food, are impracticable, the effort to edu- 
cate the peasantry in regard to the dangers of spoiled corn, 
and to show him substitutes for the more perilous varieties, 
as well as for the unwholesome corn loaves, are not vain. 
In education, even more than in government control, lies 
the hope of pellagra's enemies. For a country like the 
United States many of these measures, educational and 
otherwise, would be just as appropriate and as successful 
as in Italy. The lessons learned may be largely utilized 
by our own students of this problem, and both the 
minds and consciences of the publicists should be awak- 
ened that some of these measures be speedily inaugu- 
rated. 

In this connection it may be of interest to give some 
recommendations elucidated by Dr. Sandwith, and put 
before the British Government in the interest of the pel- 
lagra situation in Egypt: 

I. That the village authorities of Lower Egypt should 
be informed by the usual methods of the Ministry of the 
Interior that, although good maize is an excellent food, the 
habitual use of bad maize produces a disease affecting not 
only the skin, but also the digestive and nervous systems. 
The question is now of increasing importance, for corn is 
much more cultivated than it was a few years ago, in conse- 
quence of the increase of the population and the more 
bountiful supply of water. On the other hand, the wages 
of the fellaheen have nearly doubled during the last fifteen 



THE PROPHYLAXIS OF PELLAGRA 227 

years, and, therefore, they can now afford better food, in- 
cluding more meat. 

II. Maize is sold at the weekly market of every town; it 
is stored in " shunas " in all large towns, and it is, in addi- 
tion, sold as a surplus stock by the fellaheen from their 
own land to their neighbors. It seems to be impossible to 
control or inspect the sale of maize, but I think the local 
authorities should be informed that it is improper to allow 
obviously diseased maize to be exposed for sale. But it 
is not the worst maize which rinds its way into the market, 
for the worst samples cannot command a price. The poor- 
est peasants are the chief offenders, for at the end of each 
year their custom is to take, in lieu of some of their wages, a 
piece of land, which they cultivate for themselves with a 
crop of maize; the most careless of them sow diseased seed, 
gather the crop before it is ripe, store it in damp places 
before it is properly dried, and habitually eat the worst 
ears, which they cannot sell. 

The following translation, by Babcock and Lavinder, is 
an example of the kind of popular pamphlets now being 
distributed in Italy, and some of the suggestions herein 
contained may be perused with profit by health officers and 
departments interested in the subject. 

ADVICE AND RULES FOR AVOIDING PELLAGRA 

Spoiled corn is a cause of pellagra, and corn readily be- 
comes spoiled, moldy, or poisonous when harvested too 
early, before it is ripe, and stored in places which are damp 
and poorly ventilated; it may also be of poor quality when 
imported from some other place, and may contain a large 
percentage of damaged grain. 



228 PELLAGRA 

Spoiled corn may be recognized by its pale or greenish 
color, by the shrivelled and cracked surface of the grains, 
which are also covered with greenish, bluish or brownish 
spots, by its musty odor, and its bitterish and disgusting 
taste. 

The damaged corn also weighs less than sound corn, and 
the surface of spoiled grain lacks the shining appearance of 
the sound article. 

Keep your corn, then, in places well dried and aired. 
Distrust white corn, because it is more likely to spoil than 
other kinds. Imported corn is frequently damaged. 

Keep watch over your corn while it is being ground in 
the mills of the country. 

If you have carried good corn to the mill, see to it that 
you receive meal ground from that corn, and do not allow 
the miller to substitute meal ground from inferior grain. 

If your corn is ground by a roller mill, the spoiled grains 
are not likely to be ground into the meal. 

Instead of spending your money on wines and liquors, 
buy wheat bread; limit your use of polenta. If you have 
milk, eggs, cheese, limit the sale of these articles to others, 
and use at least a part of such products for your own home 
food. 

Do not be ashamed to go to the doctor if you are a pel- 
lagrin, and have yourself entered at the local sanitarium or 
at the economic kitchen. Get cured in time, and so avoid 
the hospital or the insane asylum. 

Remember that pellagrins require a curative diet. It is 
your right to demand it, and your duty to procure it. 

The cleanliness and healthfulness of your homes are 
necessary conditions for preventing the molding of corn 



THE PROPHYLAXIS OF PELLAGRA 229 

which is kept in your houses. Never keep your corn in 
bed-rooms, and see to it that you have proper places for 
the stowing and seasoning of your grain. 

Keep the corn dry. 

Exert yourselves to co-operate with others for your own 
salvation by acquiring knowledge of and interest in the 
application of the law against pellagra. 

As in this country pellagra has proved itself a disease of 
the educated and well-to-do classes, in addition to the 
poor and uneducated, some of the above would possibly 
be inapplicable; some of it, however, would apply to our 
people, and such portions might be used to advantage. 

The writer recognizes the wholesomeness and healthfull- 
ness of sound and matured corn. When the " pedigree " 
of the corn is known, when it has been allowed to properly 
dry, and has been stored in sanitary receptacles, ground 
without contamination with spoiled grain, and the meal 
protected against dampness or mold, no more eligible 
food-stuff can be named, possessing as it does an abundance 
of sustaining food elements. When, on the other hand, it 
is allowed to " spoil," to generate suspicious toxins, or to 
become an abiding place for the various molds and bacteria, 
corn then becomes an enemy, one to be both avoided and 
fought. 

Other prophylactic measures consist in the ingestion of a 
liberal, varied, and well-balanced dietary — one containing 
an abundance of the flesh proteins in fresh form, and the 
legumes also in a wholesome form. 

The studies of the Thompson-McFadden Commission 
have conclusively shown the infinitely greater spread of 
pellagra in the absence of proper facilities for disposing of 



230 PELLAGRA 

sewage. Wherever possible, a water-carriage system should 
be employed, and where this is not practicable, all precau- 
tions for screening and otherwise rendering innocuous the 
human excreta should be practised. Pellagra certainly 
flourishes in unsanitary surroundings. 

The writer trusts that the physicians who read this book 
may feel constrained to aid in the enforcement of the pure 
food laws, and to hold up the hands of those to whom the 
enforcement of these laws is their duty. 

The various law-making bodies should also be memo- 
rialized to so strengthen and amend our laws that corn may 
be frequently inspected in its journey from the field to the 
table, so that it may reach the masses of our people in a 
harmless and wholesome condition. 

The mass of the American citizens may be trusted to do 
right if it is only presented in a proper manner, and when 
the people at large wake up to a full realization of the grav- 
ity of the situation now confronting us, we may expect, as 
did our distant friends, that wise and beneficient laws will 
be put on our statute books, and enforced in every nook and 
corner of this broad land, that will make, in the not distant 
future, a fading memory of pellagra, an American problem 
that was successfully and effectually solved. 



CHAPTER X 

DESCRIPTIONS OF SOME RECENT EXPERIMENTS 
ON ANIMALS, AND DEDUCTIONS THEREFROM 

This somewhat supplementary chapter will enter into 
a discussion of some recent experiments on animals, in the 
effort to arrive at a clearer knowledge of the etiology of 
pellagra. These accounts are from Public Health Reports 
issued by the Public Health and Marine-Hospital Service, 
and reflect much credit on the able and scientific members 
of the service. 

The first is an abstract from a report by Dr. C. H. Lav- 
inder, entitled " Pellagra and its Possible Relation to Maize 
According to Some Recent Views," issued February 24, 
1911. 

Raubitschek seems to have been the first to take up, in 
an experimental way, the question as to the effects of ex- 
posure to sunlight upon maize-fed animals in association 
with the question of a possible relation to the etiology of 
pellagra. His first communication was apparently of a 
more or less prehminary character, and quite recently he 
has published a much more important paper upon the sub- 
ject. 

It is the purpose of the present article to review briefly 
this paper, as well as the papers of two other authors on 
the same subject, and to add a few details on certain mat- 
ters germain to the views expressed. 

231 



232 PELLAGRA 

In his last paper, above mentioned, Raubitschek, in his 
introduction, notes the immense mass of literature which 
has accumulated on the etiology of pellagra, and speaks in 
the harshest terms of the very questionable kind of work 
which has been done in this field. 

He also comments on the fact that only seldom have the 
somewhat scanty results of pathologico-anatomic results 
been employed in attempts to clear up its etiology, and that 
modern microbiologic, especially serologic, technic has never, 
to any extent, been so used. The work which has been 
done, he adds, is composed in great part of misinterpreted 
researches on the feeding of animals, incomplete metabolic 
investigations, and the piling up of statistical details. 

After very briefly mentioning some of the literature, he 
places the theories of the etiology of pellagra in three 
groups: the bacterial, toxic, and autotoxic. These theories 
are then briefly reviewed in a general way, and he concludes 
that not one of them in its present state can be consid- 
ered satisfactory. 

Finally, he observes that if the real cause of pellagra is 
unknown, we must not insist too closely upon bringing the 
disease into strict causal relation with the use of maize as 
food, and that, if any real progress is to be made, the above 
theories must be tested in a satisfactory experimental way, 
especially upon the pellagrin, before they can be accepted 
as of real importance. 

He then in several sections takes up his own experimental 
researches. 

He found it possible to study only briefly the numerous 
micro-organisms, which have been isolated from both 
good and spoiled maize by various workers, and presented 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 23$ 

as the cause of pellagra. The numerous molds which can 
be especially grown from spoiled corn met the same fate. 
Since raw corn is not directly consumed as food, but only 
products prepared from it, he deemed the bacteriologic 
investigation of prepared (cooked) food worthy of more 
consideration than the raw material. 

Nevertheless, in a preliminary investigation, largely as 
a matter of orientation, he did take up in a general way the 
flora of raw maize, and compared his results with the lit- 
erature. He thought certain isolated cultures which ex- 
hibited a tolerance to high temperatures were of a special 
importance in consideration of the cooking of food. 

The various bacteria and molds were too numerous for 
detailed study, so he soon confined himself to work on food 
prepared from maize, especially since he found that rela- 
tively few of the micro-organisms withstood a temperature 
of ioo° C. Such micro-organisms suggested a line of work 
looking to the establishment of an infection of the gastro- 
intestinal tract by food prepared from corn. 

With this end in view, he prepared polenta and cakes 
from both good and bad corn. These preparations were 
opened under sterile precautions, and, from the inside, cul- 
tures were made on suitable media, and grown mostly 
under aerobic conditions. In a few cases he recovered 
some species of Penicillium and Aspergillus, but chiefly the 
Bacterium maidis. Usually his cultures were sterile. 

Next he turned to the bacteriologic investigations of 
pellagrins themselves, and in this work he kept especially 
in mind the ideas of Ceni on aspergillary infections as a 
cause of pellagra. 

Blood-cultures from an arm vein were made from pella- 



234 PELLAGRA 

grins in all stages of the malady, and his results were con- 
stantly and invariably negative. Bacteriologic investiga- 
tions of the stools of pellagrins convinced him that the in- 
testinal flora of pellagrous persons differed in no essential 
way from that of healthy individuals. At first there ap- 
peared to be an unusual occurrence of the Bacterium maidis 
in pellagrous stools, but further work showed this bacte- 
rium to be, in summer, just as frequent in the stools of 
healthy persons, possibly as the result of the consumption 
of such raw foods as salads, etc. 

Finally, bacteriologic investigations of the organs of 
pellagrins a few hours after death gave essentially negative 
results. 

He concluded, therefore, that there exists no basis for 
a parasitic etiology of pellagra. 

Under the idea that pellagra is due to an almost exclu- 
sive maize diet, he thought the possible appearance of 
specific antibodies in the blood-serum of pellagrins a mat- 
ter of much importance. 

Accordingly, he prepared maize extracts, and tried, with 
proper technic, to obtain " precipitin " reaction in blood- 
sera collected from numerous pellagrins in all stages of the 
disease. The results were always positive. In this control 
work, however, with both healthy persons and animals, 
he obtained the same result. Hence he concluded that this 
reaction possesses neither diagnostic nor biologic value. 
He omitted detailed protocols as useless and unnecessary. 

In similar manner he also made use of the complement- 
fixation reaction, and here again nothing characteristic 
could be observed. His controls displayed the same result 
seen with the sera of pellagrins — viz., absence of hemolysis. 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 235 

Next, he tried experiments for hypersusceptibility in 
pellagrins and in healthy persons by means of the ophthal- 
mo- and cutaneo-reactions with various maize extracts. 
All of these results were negative. 

These experiments, he says, still leave room for proof 
how pellagrins, fed for a short time on a good mixed diet, 
would react to a suddenly administered maize diet. 

It also remains to be shown whether pellagrins, on a 
long-continued maize diet, may be sensitized from the in- 
testinal tract, and whether they would react from a new 
supply of maize albumin with the important symptoms of 
hypersensitization, such as vertigo, fever, vomiting, and 
diarrhea, all of which are important if pellagra has any 
causal relation with a maize diet. 

Still it is evident that both sound persons and pellagrins 
bear a short exclusive maize diet without reaction. 

Further experiments were made upon the phenomena of 
anaphylaxis in animals to determine the presence of maize 
antibodies. Pellagrins in all stages of the disease were 
bled from a vein of the arm, and these sera in various quan- 
tities (5 to 10 c.c.) were injected intraperitoneally into 
guinea-pigs. Twenty-four hours later intravenous injec- 
tions of the same sera (up to 3 c.c.) were made into these 
pigs. These animals showed reactions not observably dif- 
ferent from the controls injected with sera from normal 
persons. 

He concludes from the work of this section that antibodies 
specific for maize albumins (from good or bad maize) do 
not occur in the serum pellagrins. If these negative results 
do not permit any definite conclusion, still it would appear 
that from them one may infer that any causal relation 



236 PELLAGRA 

between the maize diet (good or bad) and pellagra is pure 
speculation. 

In his experiments concerning toxins he sought to deter- 
mine whether maize, naturally or artificially spoiled, would 
produce deleterious effects upon animals if used in rational 
doses. 

For this purpose he made use of good corn and spoiled 
corn obtained from pellagrous regions, ground under 
proper precautions, and extracted for twenty-four hours in 
sterile tap-water. He also made extracts from a maize 
porridge or broth which had been inoculated with various 
pure cultures, isolated either from bad maize or pellagrous 
stools. 

The extracts he obtained were variously colored, and 
some possessed a fatty-acid-like odor. They were kept a 
long while in the ice-chest under toluol without apparently 
undergoing further change. 

With these extracts he injected rabbits (subcutaneously, 
intraperitoneally, and intravenously), mice, and guinea- 
pigs (subcutaneously and intraperitoneally). In one series 
he used large doses, up to 8 c.c. ; in another series daily small 
subcutaneous doses for one to two weeks; in another series 
various extracts were daily mixed with the food of the 
animals. 

In no case were changes observed which by any means 
could be brought to show any causal relation between 
pellagra and a maize diet. Frequently the animals refused 
the food, and hence lost weight, but in no way did the ex- 
periments justify any idea whatever that corn contained a 
toxic substance which by long use may lead to pellagroid 
phenomena in animals. 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 237 

He concluded that the negative results of these experi- 
ments are worthy of note, since it would appear from them 
that not one of the above-mentioned theories is supported 
by these results, and not one seems to bear comparison 
with actual facts. 

In continuing this discussion, Raubitschek points out 
that the pellagrous erythema is usually confined to the ex- 
posed surfaces of the body, and thinks that from this it 
may be inferred either that there is a reduced resistance of 
the entire body surface, and hence exposed parts are unduly 
sensitive to slight noxious influences (sunlight), or that 
eventually, under a maize diet in the body surfaces exposed 
to sunlight, there is developed a noxious substance (noxe) 
which produces not only local morbid changes, but also 
affects the entire organism. This thought is further justi- 
fied by the usual occurrence of pellagrous skin changes at 
that season when the field laborer is most exposed to the 
sun. It is possible, then, that there may be some relation 
between a maize diet, sunlight, and pellagra. 

He directs attention to the analogy with buckwheat 
poisoning (fagopyrismus) in animals. In this connection 
white or spotted animals, exposed to the light, suffer, while 
the dark animals or white animals, kept in the dark, es- 
cape. In this condition general as well as local symptoms 
are noticed. 

The active body in the buckwheat is soluble in organic 
solvents, and seems to be a lipoid, in the wide sense, and is 
possibly related to the vegetable lipochromes. 

All these phenomena stand in near relation to the so- 
called photodynamy — viz., that, under the influence of cer- 
tain fluorescent color stuffs, the effect of light on exposed 



238 PELLAGRA 

body surfaces in animals is to produce erythema and other 
skin changes, with eventual death of the animal. It would 
seem, then, that some such idea may be entertained for a 
similar relation of things in pellagra, for in corn there occurs 
a fluorescent color stuff, and in bad corn is also found a 
characteristic red material. This idea opens up a new 
field for investigation. 

Raubitschek then describes a number of experiments 
on animals, testing as to maize diet and exposure to sun- 
light; as to the effects of the quality of the maize; the effects 
of increased intensity of light; the effects of change of diet 
after appearance of symptoms; the effects of a diet of fat- 
free maize, and the effect of feeding maize fat. 

His figures are voluminous, and some of his data quite 
difficult to comprehend. He, however, arrives at certain 
conclusions, which will be stated. He thinks he has demon- 
strated the presence of a photodynamic stuff in maize, 
and that this material is soluble in alcohol. He brings out 
strongly the effect upon the animals of changing the con- 
ditions of life without any modification of diet, and discusses 
the symptoms displayed by the animals. 

He declares that he does not attempt to bring his experi- 
mental results into a strict relation with the etiology of 
pellagra, nor to assume for this disease a photodynamic 
basis, or even to conclude that pellagra is produced by an 
almost exclusive diet of maize, good or bad, which displays 
its harmful effects first under the influence of light. The 
inference is apparent that his results are very suggestive, 
but not as yet conclusive. 

He comments on certain feeding experiments of other 
workers, and points out that the conditions of life under 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 239 

which their animals were kept may explain some of their 
irregular results. 

He notes the effect of rice diet on his animals, and says 
this cereal also is rich in fat, and by many is held account- 
able for a disease somewhat analogous to pellagra — viz., 
beriberi. 

In further discussing his conclusions, he says that the 
possibility should be borne in mind that pellagra and 
pellagroid affections may be due not only to the use of 
maize as a food, but also to the use of other grains or other 
plant stuffs which are eaten in various localities. Hence, 
observations at various places and at various times might 
help to explain the vexed question of a " pellagra without 
maize." 

This phase of the etiology of pellagra has not as yet 
attracted very much attention in America or English lit- 
erature, but is worth considering, especially as the subject 
is still sub judice. 

Lavinder comments on Raubitschek's experimental labors, 
but does not commit himself. As he remarks, the question 
of photodynamic substances and their effects is a large one, 
with a rather extensive literature. References have already 
been given to some of this. It may be briefly said, in a 
general way, that a great number of flourescent bodies, 
both vegetable and animal, which are harmless in the dark, 
have been shown to possess highly toxic properties in the 
light, especially direct sunlight. These properties include 
the power of exerting a deleterious influence on animal 
body cells and on certain protozoa. In this series of sub- 
stances are found normal constituents of the animal body, 
such as hematoporphyrin. 



240 PELLAGRA 

Fagopyrismus is an interesting condition which arises in 
white or white-spotted animals fed on buckwheat and ex- 
posed to the sunlight. It does not develop in dark ani- 
mals nor in white animals kept away from the light. It 
is not due to the buckwheat, but to other species of poly- 
gonum, and may arise from the eating not only of the green 
plant, especially at the time of flowering, but also of the 
grains, straw, stubble, and chaff. It occurs especially in 
lambs and swine, more rarely in cattle, and very rarely in 
horses. The symptoms will return even three or four weeks 
after discontinuance of the food if the animal be exposed 
to strong sunlight. In the winter the eruption is restricted 
to a mere itching and burning. 

The symptoms consist of a severe erythema of the skin 
or even a severe dermatitis, and there may be an associated 
disturbance of respiration, with general symptoms referable 
to the central nervous system, more particularly if the skin 
around the head be involved. There seems to be some 
question as to whether the condition is caused by certain 
irritant products exerting only a local action on the skin, 
with secondary general manifestations, or whether it is due 
to some toxic substance produced in the body of the animal 
under the influence of sunlight. 

Experimental work on laboratory animals, however, 
seems to show clearly that there is developed some toxic 
substance in the body of the animal. Ohmke fed rab- 
bits, mice, and guinea-pigs on buckwheat, and death re- 
sulted in the white animals exposed to diffused sunlight. 
The symptoms were loss of hair, paralytic phenomena, 
and disturbances of respiration. White animals kept in 
the dark and the gray animals showed no changes. 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 241 

The chaff as well as the grains gave the same result. 
Alcoholic extracts of the buckwheat showed a noticeable 
fluorescence, and proved just as harmful as the buckwheat, 
while the buckwheat left after extraction was harmless. 

Buckwheat poisoning in man seems to have been very 
rarely noted, and it may be said that we know very little 
of buckwheat poisoning in the human species. 

The relation between the pellagrous erythema and ex- 
posure to sunlight has always attracted attention among 
those interested in this disease, and there seems to be no 
doubt that some such relation does exist. This relation is, 
however, not always a very definite one. Pellagrous 
erythemata are not usual, but, at the same time, are not 
uncommon on covered parts of the body, and Neusser long 
ago observed that in the gypsy children of Roumania, who 
go about naked, the pellagrous erythema is usually confined 
to local situations — hands, feet, and face. It is worthy of 
note also that the dark-skinned races suffer from pellagra 
and from its erythema, and that the negro of the Southern 
States exhibits erythemas just as extensive and just as 
severe as those seen in the whites. 

If the coloring-matters of corn are of such importance as 
implied above, then it is likely that the varieties may be a 
matter of importance. The Italians, in their prophylactic 
measures, have come to regard the yellow varieties as less 
likely to undergo spoiling, and they condemn the use of 
■ white varieties. White varieties of corn are rarely seen in 
Italy. 

With regard to beriberi and rice, it is interesting to note 
that Fraser and Stanton, in their experimental work of 
feeding fowls with rice, state that alcohol-extracted rice 

16 



242 PELLAGRA 

produced the same phenomena as the rice before such extrac- 
tion, and that rice which has been proved harmless, after 
being extracted with alcohol, produced typic phenomena 
in fowls, but that if a quantity of the extract, freed of alco- 
hol, were given at the same time the birds remained well. 

Finally, it is to be remarked that the results of feeding 
experiments upon animals are very difficult of interpreta- 
tion, and conclusions can be drawn therefrom only with the 
uttermost caution. 

Feeding experiments with maize, made by workers in- 
terested in pellagra, have produced many discordant re- 
sults and varied interpretations. To apply results of this 
kind to the explanation of a specific disease of man is diffi- 
cult and uncertain. Such application must be made from 
wide knowledge, broad experience, and good judgment. 

For the purpose of further elucidating these experiments 
Dr. Lavinder issued a note regarding some experiments 
gone into by him, and his comments were issued in a bulletin 
published May 5, 191 1. The following is abstracted from 
his note: 

For the purpose of confirming these observations certain 
experiments were begun February 24th and terminated 
April 27, 191 1. 

Cages containing, first, 2 white rabbits and 1 dark one; 
second, 4 white guinea-pigs and 2 dark ones; third, 6 white 
mice; and, fourth, 4 white rats, were placed in diffused 
sunlight, and the animals were fed upon a diet of corn and 
green food (cabbage, etc.), in approximately a proportion 
of 4 of the former to 1 of the latter. Control cages on a 
mixed diet were placed along with the others. All animals 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 243 

received water freely. An exactly similar series of ani- 
mals on the same diet were placed in almost absolute dark- 
ness. 

The corn used in feeding the animals was yellow grain 
of fairly good quality, and showed no marked evidence of 
spoiling. 

For the first few days it was given uncooked; later, it 
was cooked into cakes, and this the animals seemed to pre- 
fer. It was noticed that unless great care was used in 
storing it the corn readily became moldy. 

Along with the other animals in diffused daylight was 
placed a cage containing 3 pigeons, 2 dark colored and 1 
white spotted. These were fed on an exclusive diet of 
corn which showed marked evidence of spoiling. They 
were, of course, given water. 

Generally speaking, the results of these experiments were 
entirely negative. There were several accidental deaths 
among the animals, but none displayed any such symptom- 
atology as has been described by the writers referred to. 
All of the animals except the mice did very well on the 
corn and green food diet, but did not gain as much in weight 
as did the control animals. A number of the mice died 
both in the control and in the other cages, but without dis- 
playing any characteristic phenomena. They were all 
young mice, and did not thrive in any of the cages. 

The pigeons on spoiled corn were full grown and showed 
no gain in weight. They remained well. 

No differences of consequence were noted between the 
animals kept in the dark and those exposed to the light. 

Dr. John F. Anderson, Director of the Hygienic Labora- 
tory, and Dr. Joseph Goldberger, Past Assistant Surgeon, 



244 PELLAGRA 

have issued a recent bulletin describing an attempt to infect 
the rhesus monkey with blood and spinal fluid from pella- 
grins. Their account is given verbatim: 

In the literature of pellagra there is not, so far as we 
are aware, any record of an attempt to infect by inocula- 
tion any of the higher animals, such as monkeys, with the 
blood or tissues from pellagrins. 

Sambon's theory of the transmission of pellagra by the 
buffalo gnat, or Simulium reptans, would seem to require 
that the infecting agent in pellagra be present in the blood 
at some stage of the disease. From this it follows that, if 
monkeys are susceptible, the inoculation of blood from 
cases of the disease should produce pellagra, provided the 
blood was drawn at a time when the infectious agent was 
present therein. 

During the summer of 1910 we had the opportunity of 
obtaining some blood from two well-marked cases of pel- 
lagra and spinal fluid from one of them. The blood and 
spinal fluid were used for the inoculation of Macacus rhesus 
monkeys. The details of the experiments are given in the 
following protocols: 

Case 1. — Female, G. M. This patient was a well-marked 
case of pellagra, showing the acute manifestations of the 
disease at the time the blood was taken. She was probably 
in her first attack. Her temperature at the time the blood 
was drawn was normal. 

July 16th, at 11 a. m., about 10 c.c. of blood was drawn 
from the arm vein, defibrinated, and used as follows: 

Cultures were made in fermentation tubes, which re- 
mained sterile. 

Monkey No. 1, female rhesus. At 12 noon 5 c.c. of the 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 245 

defibrinated blood from G. M. was inoculated intraperi- 
toneally. 

Monkey No. 2, female rhesus. To the fibrin and blood 
remaining in the flask in which the blood was defibrinated 
5 c.c. of normal salt solution was added. The flask was well 
shaken, 7 c.c. of the fluid drawn off, and inoculated intra- 
peritoneally. 

The temperature of both these animals was taken daily 
until October 21, 1910, when the taking of the temperature 
was discontinued, but the animals were kept under obser- 
vation until March 1, 191 1. 

On August 11, 191 1, there was noted an apparent bronz- 
ing of the face and a pinkish tint of the neck and upper chest 
of monkey No. 1. This bronzing and tinting was noted to 
be more distinct on some days and at times of day than 
at other times. It persisted for a long time without ap- 
parent increase. Nothing unusual was noted with monkey 
No. 2. 

Case 2. — Female, Mrs. G. This patient had a well- 
marked case of pellagra, with a marked erythema of hands 
and elbows and a roughened, scaly forehead. The history 
was unsatisfactory, but the conclusion was reached that 
she was probably in her second or third attack. When the 
blood and spinal fluid were taken the patient was in a low 
muttering delirium and her temperature was between 101.4 
and 102.4° F. 

On August 24, 1910, at 10: 30 a. m. blood was drawn from 
the arm vein and defibrinated. Cultures were made and 
found to be sterile. At 10: 45 a. m. about 11 c.c. of spinal 
fluid was withdrawn. Cultures were made in fermentation 
tubes and found to be sterile. 



246 PELLAGRA 

Monkey No. 3, female rhesus. At 12: 10 p. m. inocu- 
lated with 6 ex. of the defibrinated blood intraperitoneally. 

Monkey No. 4, male rhesus. At 12 : 05 p. m. inoculated 
with 6 c.c. of the defibrinated blood intraperitoneally. 

Monkey No. 5, female rhesus. At 11: 55 A.M. inoculated 
with 10 c.c. of the spinal fluid intraperitoneally. 

Daily temperatures were taken of all three of the mon- 
keys until October 21, 1910, when the taking of tempera- 
tures were discontinued. The observations, however, 
were continued until about March 1, 191 1. 

None of the monkeys presented anything worthy of 
note, except that it was thought, about September 15th, 
that monkey No. 3 showed a slight reddening of the skin 
in the region of the eyebrows. This, however, lasted only 
a few days. 

During the entire time the monkeys were kept under 
observation they were in a well-lighted room and exposed 
to a certain amount of sunlight on bright days. Their 
food was that given to other monkeys in the laboratory, it 
not being considered advisable to make any change in 
their diet, as the question it was wished to determine by 
the inoculation of the fluids from the cases of pellagra was as 
to whether the blood or the spinal fluid from such cases, 
when inoculated into monkeys, was able to produce pel- 
lagra in these animals. 

Summary. — The blood from 2 cases of pellagra and the 
spinal fluid from one of them were not infective for the 
rhesus monkeys. 

Interpretation. — The foregoing results permits of several 
interpretations. Thus it may be (1) that the rhesus 
monkey is not susceptible to pellagra; or (2) if susceptible, 



EXPERIMENTS ON ANIMALS AND DEDUCTIONS 247 

(a) that our technic in some respects was faulty, or (b) 
that, while the technic was adequate, the infective agent 
was not present in the blood or in the spinal fluid at this 
stage of the disease. 

Extending this last interpretation, one may suspect 
that the infective agent in pellagra never resides in the blood 
or spinal fluid. A final conclusion, however, is not justified. 

The writer of this book regrets that the agent etiologically 
responsible for pellagra has not been found beyond a per- 
ad venture. 

From the army of earnest students now in quest of 
this etiologic agent much may be expected, and, while we 
are zealously endeavoring to cope with the situation as it 
confronts us in this country, especially in the South, we 
look forward to a good day in the not-too-distant future 
when doubt will give way to certainty, and hypothesis will 
become assured fact, Gibraltar-like in its foundation. 



BIBLIOGRAPHIC INDEX 



ACHUCARO, 159 

Adoardi, 14 

Alessandrini and Scala, 71 

Allen, 104 

Alphonse de Candolle, 35 

Anderson and Goldberger, 243 

Antonini, in 

Antonini and Marianni, 188 

Aubert, 116 

Babcock, 13, 27, S3, 65, 80, 85, 91, 
93, 109, 116, 117, 124, 139, 188, 209 
Babcock and Lavinder, 227 
Babcock and Watson, 20 
Babes, 96, 187 
Babes and Manicatide, 49 
Babes and Sion, 13, 45, 80, no 
Baillarger, 116 
Balardini, 39, 44 
Ballardino, 15 
Bardin, 160, 161, 162, 163 
Barrett and Smith, 199 
Baruch, 201 
Baruino, 13 
Batten, 156 
Behnondo, 49 
Bemis, 27 
Bianchi, 112 
Boltri, 221 
Bonafous, 35 

Brown and Carruthers, 20 
Brown and Low, 20 
Bucknill and Tuke, no 

Campbell, 56, 131 
Carruthers and Brown, 20 
Casal, 14, 19, 34, 88 
Casenave, 177 



Cattaneo, 220 

Ceconni, 51 

Ceni, 233 

Ceresoli, 221, 222 

Clerici, 112 

Cleveland, S3 

Cole and Winthrop, 188 

Crenshaw, 210 

Cuboni, 41 

Cudd, 189 

Curry, 130 

Cutting, Jr., 62, 214, 216 

Darwin, 35 
Daves, 139 
De Giaxa, 50 
Delavan, 142 
D'Oleggio, 14 

Erba, 49 

Ferrati, 49 

Fileti, 43 

Finch, 142 

Fine, 68 

Finzi, 116, 119 

Finzi and Vedrani, 117 

Fox, 87, 88, 90, 139, 142 

Frapolli, 12, 14 

Fraser and Stanton, 241 

Garrison, 68 

Gaumer, 24 

Goldberger, 62, 73, 74, 76, 194, 211 

Goldberger and Anderson, 243 

Gosio, 49, 217 

Gray, 25, 160 

Gregor, 116, 117, 118 

249 



250 



BIBLIOGRAPHIC INDEX 



Griesinger, 112 
Griffini, 166 

Hameau, 18 

Harris, 29, 81, 176 

Hausemann, 49 

Hebra, 202 

Heider and Paltauf, 41 

Hewett, 30, 132, 139 

Hillman, 68 

Hillman and Schule, 163 

Hinsdale, 202 

Hippocrates, 201 

Hirsch, 20 

Holland, 107 

Howard, 54 

Humboldt, 35 

Hunter, 54 

Jennings, 68 
Jones, 130 

Kerr, 26 
King, 12, 68 
Koch, 42, 187 

Landouzy, 51 

Lavinder, 18, 21, 44, 46, 48, 154, 180, 

231, 239, 242 
Lavinder and Babcock, 227 
LeFrer, 51 
Lombroso, 40, 42, 44, 45, 49, 56, 76, 

78, no, 117, 180, 184, 185, 188 
Long, 159 
Lorenz, 155 
Low and Brown, 20 

Majocchi, 40 

Manicatide and Babes, 49 

Manning, 23 

Manson, 23, 51 

Marchand, 18 

Marchi, 157, 158 

Mariani, 49 

Marianni and Antonini, 188 

Marie, 13, 22, 37, 38, 41, 100, 159 

Mazari, 34 



McFadden, 63, 68, 229 
McNeal, 68 
Merk, 88, 93 
Mesnil, 54 
Mizell, 57 
Mobley, 124 
Mongeri, 112 
Monti and Tirelli, 42 
Morselli, no 
Mott, 156 
Myers, 68 

Neusser, 50, 241 

Niles, 28, 31, 34, 46, 64, 81, 82, 84, 
89, 95, 96, 104, 105, 125, 148, 169, 
192, 198, 199, 205, 207, 208 

Ohmke, 240 

Pal and Weigert, 157, 158 

Paltauf and Heider, 41 

Pelizzi, 49 

Pellogio, 49 

Perry, 142, 143 

Petit, 18 

Piannetta, 116 

Pope, 27 

Procopiu, 84, 93, 114, 127 

Primer, 20 

Raubitschek, 231, 232, 237, 238, 

239 
Regis, 18, 113, 116 
Roncoroni, 101 
Roussel, 51, 79, 83, 93, in, 213 

Salerio, 109 

Sambon, 17, 20, 54, 55, 244 

Sandwith, 20, 21, 81, 91, 108, 126, 

128, 146, 155, 156, 158, 226 
Santa Rosa de Victerbo, 35 
Scala and Alessandrini, 71 
Scheube, 91, 127 
Schule and Hillman, 163 
Scipione, 13 
Sherwell, 27 
Siler, 68, 71 



BIBLIOGRAPHIC INDEX 



251 



Sion and Babes, 13, 45, 80, no 

Sloan, 27 

Smith and Barrett, 199 

Stanton and Fraser, 241 

Strachan, 21, 23 

Strambio, 14, 78. 79, 93, 96, no, 113, 

177 
Strobe, 158 

Tanzi, 115, 116, 119, 120 

Taylor, 68 

Thompson, 63, 68, 229 

Thrash, 163, 165, 167 

Tirelli, 49 

Tirelli and Monti, 42 

Tonnini, ioi, 102, 103 

Triller, 18, 19 

Tucker, 30 

Tuczek, 117, 154, 156 

Tuke, 109 

Tuke and Bucknill, no 



Tyler, 25 
Typhaldos, 20, 47 

Van Giesen, 157 
Vedrani, 116, 119 
Vedrani and Finzi, 117 
Verga, 116 

Warnock, 21, 102, 116, 146, 188 
Watson, 87, 88, 89, 90, 127, 139 
Watson and Babcock, 29 
Weigert and Pal, 157, 158 
Whaley, 125 
Williams, 23 
Winthrop and Cole, 188 
Wolff, 65, 139, 141 
Wollenberg, 180 
Wood, 188 
Wright, 68 

Zletarovic, 117 



INDEX 



Acid, hydrochloric, absence, treat- 
ment, 207 

Aerophagia, 95 

Africa, pellagra in, history, 20 

Akoria, 94 

Alcohol, 196 

Alcoholism, 129 

Alpine scurvy, n 

Amenorrhea, 130 

Amentia, 115, 120 

Amylophagia, 56 

Anal irritation, 92 

Anatomy, morbid, 154 

Andersonville Prison, pellagra in, 
during Civil War, 25, 26 

Anesthesia, 102 

Aniline-blue-black stain for spinal 
cord, examination in, 157 

Animals, experiments on, 231 

Ankylostomiasis, 128 

Anorexia, 94 
treatment, 207 

Anxiety psychoses, 122 

Aphthous ulcers, treatment, 205 

Appendicitis, 131 

Appendix fasciolea, 88 

Appetite, loss of, 94 
treatment, 207 

Arsacetin, 187 

Arsenic, 185, 187, 206 

Artificial drying of corn, 219 

Aspergillus glaucus, 40 

Asturian leprosy, 1 1 
rose, 11 

Atoxyl, 187 

Atropin for salivation, 205 

Austria, pellagra in, history, 20 



Babes and Sion's classification, 80 
Bacterium maidis, 40 

termo, 41 
Bakeries, rural, 222 
Band, neck, 88 
Bath, 185, 200 

cold, 202 

hot, 200, 202 

salt, 203 

warm full, 202 
Beans, 195 
Blood changes, 160 

occult, in stomach, 83 

transfusion of, 188 
Bones, brittleness of, 154, 166 
Brain, changes in, 155, 164 
Buba Tranjilar, 19 
Buccal infection, 199 

redness, 83 
Bulimia, 94 
Buttermilk, 193 

Cachexia, 79, 154, 155 

Cardinal tongue, 84 

Case-reports, 132 

Catalepsy, psychical, no 

Cephalalgia, 104 

Cereals, 195 

Cerebrospinal fluid, 155 

Chemical tests for spoiled corn, 217 

Children, pellagra in, 66 

Civil War, pellagra in, 25 

Climatic treatment, 211 

Clinical reports and description of 

cases, 132 
Cold bath, 202 
Colon irrigation, 190 

253 



254 



INDEX 



Commencing pellagra, 79 
Complications, 128 
Confirmed pellagra, 79, 177 
Constipation, 95, 207 
Constitutional treatment, 205 
Continuous pellagra, 79 
Contractures in pellagra, 99 
Corfu, pellagra in, history, 19 
Corn. See Maize. 
Corn-bread poison, 81 
Course, 77, 176 
Cretinism, 130 

Definition, ii 
Delirium, acute, 121 
Dementia, no, 118 
Derivation of word pellagra, 12 
Desiccation, artificial, of corn, 219 
Desiccators, 220 
Diagnosis, 168 

differential, 175 

positive, 172 
Diarrhea, 96, 97 

treatment, 207 
Diet, 185, 192, 194, 229 

Goldberger's, 194 
Digestive symptoms, 93 
Douche, rectal, 203 

Scotch, 203 

vaginal, 204 
Drainage of gall-bladder, 190 
Drying, artificial, of maize, 219 
Dysentery, 96 
Dyspepsia, 93 
Dysphagia, 98 

Eczema and pellagra, differentia- 
tion, 87 
Eggs, 193, 194 

Egypt, pellagra in, history, 21 
Electric reactions, 101 
Emetin, 199, 205 
England, pellagra in, history, 20 
Eosinophilia, 161 
Epigastralgia, 93 
Epilepsy, pellagrous, no 
Erythema, 86 



Erythema multiforme and pellagra, 
differentiation, 88 
treatment, 209 
Esophagus, burning of, 94 
Etiology, 34 

European war, pellagra and, 21 
Eurotium herbariorum, 40 
Exchanges, corn, 222 
Experiments on animals, 231 
Eye symptoms, 125 

Facial expression, 106 
Fagopyrismus, 237, 240 
Feces, odor of, 96 
Feeding, forced, 193 
Fever, 125 
Flatulence, 95 
Forced feeding, 193 
Fowler's solution, 206 
Fragilitas ossium, 154, 166 
France, pellagra in, history, 18 

Gait, 102 

Gall-bladder, drainage, 190 

Gastric lavage, 204 

symptoms, 82 

ulcer, 95 
Goiter, 130 

Gosio's test for spoiled corn, 217 
Great Britain, pellagra in, 20 

Habits in etiology, 66 

Headache, 104 

Heart, changes in, 166 

Hemorrhoids, 97 

Heredity as predisposing factor, 64 

Hexamethylenamin, 208 

History, 11, 12 

clinical, of cases, 132 

Hook-worm disease, 128 

Hot bath, 200, 202 

Hydrochloric acid, absence, treat- 
ment, 207 

Hydromania, 112, 113 

Hydrotherapy, 200 

Hygienic treatment, 197 



INDEX 



255 



Hyperalgesia, 103 
Hyperthyroidism, 130 

ICHTHYOL, 208 

Idiocy, 115, 120 

Indian corn. See Maize. 

Insanity, no, 112, 114 

acute confusional, 1 20 

maniac-depressive, 123 
Insolation, vernal, 14 
Insomnia, 106 

treatment, 210 
Intermittent pellagra, 78 
Intestines, changes in, 154, 164 
Iodids, 210 
Iron, 185 

arsenite solution, 206 
Irrigation of colon, 190 
Italy, pellagra in, history, 14 
prevention, 214 

Jamaica, pellagra in, history, 21 
Jews, pellagra in, 65 

Katatonia, 122 
Kidneys, changes in, 166 

Laxdes, diseases of, n 

Lange's colloidal gold chlorid test, 

155 
Lavage, gastric, 204 
Lavinder's theory, 44 
Lead acetate, 185 
Legumes, 195 
Leprosy, Asturian, n 
Light, avoidance, 198 
Linolin as cause, 57 
Liver, changes in, 166 
Lombroso's theory, 44 

treatment, 184, 185 
Lungs, changes in, 156 
Lupus erythematosus and pellagra, 

differentiation, 90 
Lymphocytes, increase in, 162, 163 

Matdismtjs, 11 
Maize, 35 



Maize, artificial drying, 219 
distribution of, 35 
exchanges, 222 
history of, 35 
photodynamic substances in, 237, 

238, 239 
public storehouses, 221 
spoiled, as cause of pellagra, 35, 44 
Gosio's test, 217 
micro-organisms in, 39 
moulds of, 41 
parasites of, 39 
prohibition of, 216 
red oil of, 38 
resinous substance of, 39 
substances yielded by, 38 
tests for, 37, 217 
toxic substance of, 39 
weevils, 37 
Mai de la Rosa, 12 
Misere, 12 
Rosa, 14 
del Padrone, 12 
Sole, 12 
Maladie de la Teste, 18 
Malaria, treatment, 207 
Malarial multiple neuritis, 21 
Mania, 114, 115 
Maniac-depressive insanity, 1 23 
Marasmus, 130 

Marchi's stain for spinal cord, ex- 
amination in, 157 
Massage, 209 

McFad den-Thompson Pellagra Com- 
mission, 68-71 
Mealies, 36 
Meat, 192, 195 
Medicinal treatment, 204 
Melancholia, 107, no, in, 115 
Menorrhagia, 130 
Mental symptoms, 105 

treatment, 210 
Mexico, pellagra in, history, 23 
Micro-organisms in spoiled corn, 39 
Milk, 193, 194 
Mizell's theory, 57 
Morbid anatomy, 154 



256 



INDEX 



Morbus miseriae, 51 
Mortality, 179 
Moulds of spoiled corn, 41 
Mouth, care of, 199 
sore, 84, 85 
treatment, 205 
Multiple neuritis, malarial, 21 
Muscular spasms, 101 

Neck band, 88 
Negro, pellagra in, 65 
Neosalvarsan, 190 
Nervous symptoms, 98 
treatment, 208, 209 
system, changes in, 154, 158, 159 
Neuralgia, ovarian, 131 
Neurasthenia, 117 
Neuritis, malarial multiple, 21 
Noxe, 237 

Occult blood in stomach, 83 

Occupation in etiology, 66 

Ocular symptoms, 1 25 

Odor of stools, 96 

Oidium lactis maidis, 40 

Oil, olive, 194 
red, of spoiled corn, 38 
semidried edible, as cause, 57 

Olive oil, 194 

Ovarian neuralgia, 131 

Pain, sensibility to, 102 
Pains, shooting, 85 

treatment, 208 
Paraffin liquid, 208 
Paralysis, no, in, 113 
Paralytic pellagra, 79 
Parasites of spoiled corn, 39 
Pathology, 154 
Peas, 195 
Pellagra, absence of hydrochloric 

acid in, treatment, 207 
acute confusional insanity in, 120 

delirium in, 121 

dementia in, 118 
aerophagia in, 95 
akoria in, 94 



Pellagra, alcohol in, 196 

alcoholism in, 1 29 

amenorrhea in, 130 

amentia in, 115, 120 

anal irritation in, 92 

and eczema, differentiation, 87 

and erythema multiforma, differ- 
entiation, 88 

and lupus erythemata, differen- 
tiation, 90 

and potable waters, 71 

anesthesia in, 102 

ankylostomiasis in, 128 

anorexia in, 94 
treatment, 207 

anxiety psychoses in, 122 

aphthous ulcers in, treatment, 205 

appendicitis in, 131 

appendix fasciolea in, 88 

arsacetin in, 187 

arsenic in, 185, 187, 206 

atoxyl in, 187 

avoidance of light in, 198 

Babes and Sion's classification, 80 

baths in, 185, 200 

beans in, 195 

blood changes in, 160 

brittleness in bones in, 154, 166 

buccal infection in, 199 
redness in, 83 

bulimia in, 94 

burning of esophagus in, 94 
of stomach in, 94 

buttermilk in, 193 

cachexia in, 154, 155 

care of mouth in, 199 
of teeth in, 199 

cases of, clinical reports, 132 

cephalalgia in, 104 

cereals in, 195 

cerebrospinal fluid in, 155 

changes in blood in, 160 
in brain in, 155, 164 
in heart in, 166 
in intestines in, 154, 164 
in kidneys in, 166 
in liver in, 166 



INDEX 



257 



Pellagra, changes in lungs in, 156 
in nervous system in, 154, 158, 

159 

in skin in, 166 

in spinal cord in, 156 

in spleen in, 166 
classification of , 78 
climatic treatment, 211 
clinical course, 71 
cold bath in, 202 
commencing, 79 
Commission, Thompson-McFad- 

den, 68-71 
complications, 128 
confirmed, 79, 177 
constipation in, 95 

treatment, 207 
constitutional treatment, 205 
continuous, 79 
contractures in, 99 
course of, 77, 176 
cretinism in, 130 
cure, 103 
definition, 11 
delirium in, acute, 121 
dementia in, no, 118 
derivation of word, 12 
diagnosis, 168 

differential, 175 

history of case, 171 

positive, 172 
diarrhea in, 96, 97 

treatment, 207 
diet in, 185, 192, 194, 229 
digestive symptoms, 93 
drainage of gall-bladder in, 190 
dysentery in, 96 
dyspepsia in, 93 
dysphagia in, 98 
eggs in, 193, 194 
electric reactions in, 101 
emetin in, 199, 205 
eosinophilia in, 161 
epigastralgia in, 93 
epilepsy in, no 
eruption on skin in, 86 
erythema in, 86 
17 



Pellagra, erythema in, treatment, 

209 
etiology of, 34 

habits, 66 

heredity, 64 

linolin, 57 

occupation, 66 

race, 65 

season, 67 

semidried edible oils, 57 

sex, 65 

simulium theory, 53 

spoiled maize, 35, 44 

unhygienic surroundings, 63 
European war and, 21 
eye symptoms, 125 
facial expression in, 106 
fever in, 125 
first degree, 79 
flatulence in, 95 
forced feeding in, 193 
Fowler's solution in, 206 
fragilitas ossium in, 154, 166 
gait in, 102 
gastric lavage in, 204 

symptoms, 82 

ulcer in, 95 
general considerations, 11 
goiter in, 130 
Goldberger's diet in, 194 
gynecologic complications, 130 
habits in, etiology of, 66 
headache in, 104 
hemorrhoids in, 98 
heredity as predisposing factor, 64 
hexamethylenamin in, 208 
history, 11, 12 
hook-worm disease in, 128 
hot bath in, 200, 202 
hydromania in, 112, 113 
hydrotherapy in, 200 
hygienic treatment, 197 
hyperalgesia in, 103 
hyperthyroidism in, 130 
ichthyol in, 208 
idiocy in, 115, 120 
in Africa, history, 20 



258 



INDEX 



Pellagra in Andersonville Prison 
during Civil War, 25, 26 

in Austria, history, 20 

in children, 66 

in Civil War, 25 

in Corfu, history, 19 

in Egypt, history, 21 

in England, history, 20 

in France, history, 18 

in Great Britain, 20 

in Italy, history, 14 
prevention, 214 

in Jamaica, history, 21 

in Jews, 65 

in Mexico, history, 23 

in negro, 65 

in Roumania, history, 19 

in Southern States, 27 

in Spain, history, 13, 18 

in United States, 25 

in Yucatan, history, 23 

increase in lymphocytes in, 162, 

163 
insanity in, no, 112, 114 
insomnia in, 106 

treatment, 210 
intermittent, 78 
iodids in, 210 
iron in, 185 

arsenite solution in, 206 
irrigation of colon in, 190 
katatonia in, 122 
Lange's colloidal gold chlorid test 

in, 155 
Lavinder's theory, 44 
lead acetate in, 185 
legumes in, 195 
linolin as cause, 57 
Lombroso's theory, 44 

treatment, 184, 185 
loss of appetite in, 94 

treatment, 207 
lymphocytes in, increase in, 162, 

163 
malaria complicating, treatment, 

207 
mania in, 114, 115 



Pellagra, maniac-depressive insanity 

in, 123 
marasmus in, 130 
massage in, 209 
meat in, 192, 195 
medicinal treatment, 204 
melancholia in, 107, no, in, 115 
menorrhagia in, 130 
mental symptoms, 105 

treatment, 210 
milk in, 193, 194 
Mizell's theory, 57 
morbid anatomy, 154 
mortality, 179 
mouth in, care, 199 
muscular spasms in, 101 
neck band in, 88 
neosalvarsan in, 190 
nervous symptoms, 98 

treatment, 208, 209 
neurasthenia in, 117 
occult blood in stomach in, 83 
occupation in, etiology of, 66 
ocular symptoms, 1 25 
odor of feces in, 96 
olive oil in, 194 
ovarian neuralgia in, 131 
pains in, 85 

treatment, 208 
paraffin liquid in, 208 
paralysis in, 79, no, in, 113 
pathology, 154 
peas in, 195 

pigmentary degenerations in, 167 
potable waters and, 71 
potassium iodid in, 206 
pregnancy in, 130 
prodromal period, 81 
prognosis, 179 
pronunciation, 12 
prophylaxis, 213 

advice and rules, 227 
pruritus in, 105 
psychic symptoms, 105 

treatment, 210 
psychical catalepsy in, no 
pyorrhea alveolaris in, 129, 199 



INDEX 



259 



Pellagra, race in etiology of, 65 
Raubitschek's experiments, 231 
rectal douche in, 203 
reflexes in, 101 
remittent, 79 
rest in, 197 
Rontgen ray in, 198 
Roussel's classification, 79 
saliva in, 84 

salivation in, atropin for, 205 
salt bath in, 203 
salvarsan in, 190, 210 
Sambon's theory, 52, 244 
scarlet-red ointment in, 209 
Scotch douche in, 203 
season in, etiology of, 67 
second degree, 79 
semidried edible oils as cause, 57 
sensibility to pain in, 102 

to touch in, 102 
serum treatment, 188 
sex in etiology of, 65 
sexual desire in, 104 
shooting pains in, 85 

treatment, 208 
simulium theory, 53 
sine pellagra, 93, 175 
sitophobia in, 94 
skin reflexes in, 101 

symptoms, 86 
smell in, 104 
soamin in, 187, 188 
sodium acetyl arsanilate in, 187 

arsanilate in, 187 

cacodylate in, 206 

chlorid in, 185 
sore mouth in, 84, 85 
treatment, 205 

tongue in, treatment, 205 
spoiled corn as cause, 33, 44 
Strambio's classification, 78 
supra-acute, no 
surgical treatment, 189 
symptoms of, 77 

digestive, 93 

gastric, 82 

mental, 105 



Pellagra, symptoms of, nervous, 98 

ocular, 125 

psychic, 105 

skin, 86 
synonyms, n 
syphilis in, 130 
tannigen in, 207 
taste in, 105 
teeth in, care, 199 
temperature in, 125 
thermal phenomena, 125 
third degree, 79 
thyroid disease in, 130 
tongue in, 83, 84, 85 
transfusion of blood in, 188 
treatment, 184 

climatic, 211 

constitutional, 205 

dietetic, 191 

hydrotherapeutic, 200 

hygienic, 197 

medicinal, 204 

prophylactic, 213 

surgical, 189 
tremors in, 99 

tuberculosis complicating, 161 
typhoid, no, in, 126 

prognosis, 182 
unhygienic surroundings as cause, 

63 

vaginal douche in, 204 
irritation in, 92 

vegetables in, 195 

vomiting in, 94 

vulvar irritation in, 91, 92 

warm full bath in, 202 

Wassermann test in, 155 

water drinking in, 204 

wet cases, 92 

*-ray in, 198 

Zeist theory, 34 
Pellagrocein, 39 
Pellagrous cachexia, 79 

tetanus, no 
Pellagrozeina, 40 
Pellarella, 12, 14 
Penicillium, 40 



26o 



INDEX 



Penicillium glaucum, 40 
Photodynamic substances in maize, 

237, 238, 239 
Pigmentary degenerations, 167 
Poison, corn-bread, 81 
Potable waters, pellagra and, 71 
Potassium iodid, 206 
Pregnancy, 130 
Prison, Andersonville, pellagra in, 

during Civil War, 25, 26 
pellagra in, during Civil War, 25 
Prodromal period, 81 
Prognosis, 179 
Pronunciation, 12 
Pruritus, 105 
Pseudopellagra, 51 
Psychic symptoms, 105 

treatment, 210 
Psychical catalepsy, no 
Psychoneurosis Maidica, n 
Psychoses, anxiety, 122 
Public storehouses for corn, 221 
Pyorrhea alveolaris, 129, 199 

Race in etiology, 65 

Raubitschek's experiments, 231 

Rectal douche, 203 

Red oil of spoiled corn, 38 

Redness, buccal, 83 

Reflexes, 101 

Remittent pellagra, 79 

Resinous substance of spoiled corn, 

39 
Rest, 197 
Rontgen ray, 198 
Rose, Asturian, n 
Roumania, pellagra in, history, 19 
Roussel's classification, 80 
Rub, salt, 203 
Rural bakeries, 222 

Saliva, 84 

Salivation, atropin for, 205 
Salt bath, 203 
Salvarsan, 190, 210 
Sambon's theory, 52, 244 
Scarlet-red ointment, 209 



Scorbutus alpinus, 14 
Scotch douche, 203 
Scurvy, Alpine, n 
Season in etiology, 67 
Serum treatment, 188 
Sex in etiology, 65 
Sexual desire, 104 
Shooting pains, 85 
treatment, 208 
Silver nitrate in sore mouth, 205 
Simulium ornatum, 54 

pecarum, 54 

pubescans, 54 

reptans, 53, 54, 244 

theory, 53 

venistum, 54 
Sitophobia, 94 
Skin, changes in, 166 

reflexes, 101 

symptoms, 86 
Smell, 104 
Soamin, 187, 188 
Sodium arsanilate, 187 

cacodylate, 206 

chlorid, 185 
Sore mouth, 84, 85 
treatment, 205 

tongue, treatment, 205 
Southern States, pellagra in, 27 
Spain, pellagra in, history, 13, 18 
Spasms, muscular, in pellagra, 101 
Spinal cord, changes in, 156 
Spleen, changes in, 166 
Sporisorium maidis, 39 
Sporothricum maidis, 40 
Stain, analin-blue-black, for spinal 
cord, examination in, 157 

Marchi's, for spinal cord, examina- 
tion in, 157 

Van Giesen's, for spinal cord, ex- 
amination in, 157 

Weigert-Pal, for spinal cord, ex- 
amination in, 157 
Stomach, burning of, 94 

lavage, 204 
Stools, odor of, 96 
Storehouses, public, for corn, 221 



INDEX 



261 



Strachan's disease, 22 
Strambio's classification, 78 
Stuporous dementia, 118 
Sunlight, avoidance, 198 
Symptoms, 77 
Synonyms, 11 
Syphilis, 130 

Tannigen, 207 

Taste, 105 

Teeth, care of, 199 

Temperature, 125 

Test, Wassermann, 155 

Tests for spoiled corn, 37, 217 

Tetanus, no 

Thermal phenomena, 125 

Thompson-McFadden Pellagra Com- 
mission, 68-71 

Thyroid disease, 130 

Tongue, 83, 84, 85 
cardinal, 84 
sore, treatment, 205 

Touch, sensibility to, 102 

Transfusion of blood, 188 

Treatment, 184 

Tremors, 99 

Tuberculosis, 161 

Typhoid pellagra, no, in, 126 
prognosis, 182 

Typhus pellagrosus, 127 



Ulcer, aphthous, treatment, 205 

gastric, 95 
United States, pellagra in, 25 

Vaginal douche, 204 

irritation, 92 
Van Giesen's stain for spinal cord, 

examination in, 157 
Vegetables, 195 
Vernal insolation, 14 
Vomiting, 94 
Vulvar irritation, 91, 92 

War, Civil, pellagra in, 25 
European, pellagra and, 21 

Warm full bath, 202 

Wassermann test, 155 

Water, drinking-, 204 

Waters, potable, pellagra and, 71 

Weigert-Pal stain for spinal cord, 
examination in, 157 

Wet cases, 92 

X-ray, 198 

Yucatan, pellagra in, history, 2$ 

Zeist theory of pellagra, 34 



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the important literature very carefully, over 2300 references being utilized. This, 
coupled with Dr. Xorris' large experience, gives his book the stamp of authority. 
The chapter on serum and vaccine therapy and organotherapy is particularly 
valuable because it expresses the newest advances. Every phase of the subject 
is considered: History, bacteriology, pathology, sociology, prophylaxis, treatment 
(operative and medicinal), gonorrhea during pregnancy, parturition and puer- 
perium, diffuse gonorrheal pertitonitis, and all other phases. Furthur, Dr. Xorris 
also considers the rare varieties of gonorrhea occurring in men, women, and 
children. The text is illustrated. 

American Text-Book qf Gynecology 

Second Revised Edition 
American Text=Book of Gynecology. Edited by J. M. Baldy, 
M. D. Imperial octavo of 718 pages, with 341 text-illustrations and 
38 plates. Cloth, 56.00 net. 

American Text-Book of Obstetrics 

Second Revised Edition 
The American Text=Book of Obstetrics. In two volumes. Edited 
by Richard C. Xorris, M. D. ; Art Editor, Robert L. Dickinson, M. D. 
Two octavos of about 600 pages each ; nearly 900 illustrations, includ- 
ing 49 colored and half-tone plates. Per volume : Cloth, 33.50 net 

" As an authority, as a book of reference, as a ' working book ' for the student or practi- 
tioner, we commend it because we believe there is no better.' ' — American Journal of the 
Medical Sciences. 



SAUNDERS' BOOKS ON 



Ashton's 
Practice of Gynecology 



The Practice of Gynecology. By W. Easterly Ashton, M. D., 
LL.D., Professor of Gynecology in the Medico-Chirurgical College, 
Philadelphia. Handsome octavo volume of I ioo pages, containing 1058 
original line drawings. Cloth, $6.50 net; Half Morocco, $8.00 net. 

NEW (5th) EDITION 

The continued success of Dr. Ashton's work is not surprising to any one 
knowing the book. The author takes up each procedure necessary to gynecologic 
step by step, the student being led from one step to another, just as in studying 
any non-medical subject, the minutest detail being explained in language that 
cannot fail to be understood even at first reading. Nothing is left to be taken for 
granted, the author not only telling his readers in every instance what should be 
done, but also precisely how to do it, A distinctly original feature of the book is 
the illustrations, numbering 1058 line drawings made especially under the author's 
personal supervision from actual apparatus, living models, and dissections on the 
cadaver. 

From its first appearance Dr. Ashton's book set a standard in practical 
medical books ; that he has produced. a work of unusual value to the medical 
practitioner is shown by the demand for new editions. Indeed, the book is a 
rich store-house of practical information, presented in such a way that the. work 
cannot fail to be of daily service to the practitioner. 

Howard A. Kelly, M. D. 

Professor of Gynecologic Surgery, Johns Hopkins University. 

" It is different from anything that has as yet appeared. The illustrations are particularly 
clear and satisfactory. One specially good feature is the pains with which you describe so 
many details so often left to the imagination." 

Charles B. Penrose, M. D. 

Formerly Professor of Gynecology in the University of Pennsylvania 

" I know of no book that goes so thoroughly and satisfactorily into all the details of every- 
thing connected with the subject. In this respect your book differs from the others." 

George M. Edebohls, M. D. 

Professor of Diseases of Women, New York Post-Graduate Medical School 
" A text-book most admirably adapted to teach gynecology to those who must get theil 
knowledge, even to the minutest and most elementary details, from books." 



GYNECOLOGY AND OBSTETRICS 



Bandler's 
Medical Gynecology 



Medical Gynecology. By S. Wyllis Bandler, M. D., Adjunct 
Professor of Diseases of Women, New York Post-Graduate Medical 
School and Hospital. Octavo of 790 pages, with 150 original illus- 
trations. Cloth, $5.00 net ; Half Morocco, #6.50 net. 

NEW (3d) EDITION— 60 PAGES ON INTERNAL SECRETIONS 

This new work by Dr. Bandler is just the book that the physician engaged in 
general practice has long needed. It is truly the practitioner' s gynecology — planned 
for him, written for him, and illustrated for him. There are many gynecologic 
conditions that do. not call for operative treatment ; yet, because of lack of that 
special knowledge required for their diagnosis and treatment, the general practi- 
tioner has been unable to treat them intelligently. This work not only deals 
with those conditions amenable to non-operative treatment, but it also tells how to 
recognize those diseases demanding operative treatment. 

American Journal of Obstetrics 

" He has shown good judgment in the selection of his data. He has placed most emphasis 
on diagnostic and therapeutic aspects. He has presented his facts in a manner to be readily 
grasped by the general practitioner." 



Bandler's Vaginal Celiotomy 

Vaginal Celiotomy. By S. Wyllis Bandler, M. D., New York 

Post- Graduate Medical School and Hospital. Octavo of 450 pages, with 
148 original illustrations. Cloth, $5.00 net; Half Morocco, $6.50 net. 

SUPERB ILLUSTRATIONS 

The vaginal route, because of its simplicity, ease of execution, absence of 
shock, more certain results, and the opportunity for conservative measures, con- 
stitutes a field which should appeal to all surgeons, gynecologists, and obstetricians. 
Posterior vaginal celiotomy is of great importance in the removal of small tubal 
and ovarian tumors and cysts, and is an important step in the performance of 
vaginal myomectomy, hysterectomy, and hysteromyomectomy. Anterior vaginal 
celiotomy with thorough separation of the bladder is the only certain method 
of correcting cystocele. 

The Lancet, London 

" Dr. Bandler has done good service in writing this book, which gives a very clear descrip- 
tion of all the operations which may be undertaken through the vagina. He makes out a 
strong case for these operations." 



SAUNDERS' BOOKS ON 



Kelly and Noble's 

Gynecology 

arid Abdominal Surgery 



Gynecology and Abdominal Surgery. Edited by Howard A. 
Kelly, M. D., Professor of Gynecology in Johns Hopkins University ; 
and Charles P. Noble, M. D., formerly Clinical Professor of Gyne- 
cology in the Woman's Medical College, Philadelphia. Two imperial 
octavo volumes of 950 pages each, containing 880 illustrations, some in 
colors. Per volume: Cloth, $8.00 net; Half Morocco, $9.50 net. 

TRANSLATED INTO SPANISH 
WITH 880 ILLUSTRATIONS BY HERMANN BECKER AND MAX BRODEL 

In view of the intimate association of gynecology with abdominal surgery the 
editors have combined these two important subjects in one work. For this reason 
the work will be doubly valuable, for not only the gynecologist and general prac- 
titioner will find it an exhaustive treatise, but the surgeon also will find here the 
latest technic of the various abdominal operations. It possesses a number of 
valuable features not to be found in any other publication covering the same fields. 
It contains a chapter upon the bacteriology and one upon the pathology of gyne- 
cology, dealing fully with the scientific basis of gynecology. In no other work 
can this information, prepared by specialists, be found as separate chapters. 
There is a large chapter devoted entirely to medical gynecology written especially 
for the physician engaged in general practice. Heretofore the general practitioner 
was compelled to search through an entire work in order to obtain the information 
desired. Abdominal surgery proper, as distinct from gynecology, is fully treated, 
embracing operations upon the stomach, upon the intestines, upon the liver and 
bile-ducts, upon the pancreas and spleen, upon the kidneys, ureter, bladder, and 
the peritoneum. The illustrations are truly magnificent, being the work of Mr. 
Hermann Becker and Mr. Max Brbdel. 

American Journal of the Medical Sciences 

" It is needless to say that the work has been thoroughly done: the names of the authors 
and editors would guarantee this ; but much may be said in praise of the method of presen- 
tation, and attention may be called to the inclusion of matter not to be found elsewhere." 



G YNECOLOG Y AND OBSTETRICS 



Webster's 
Text-Book qf Obstetrics 

A Text-Book of Obstetrics. By J. Clarence Webster, M. D. 
(Edin.), F. R. C. P. E., Professor of Obstetrics and Gynecology in Rush 
Medical College, in affiliation with the University of Chicago. Octavo 
volume of 767 pages, illustrated. Cloth, $5.00 net; Half Morocco, 
$6.50 net. 

BEAUTIFULLY ILLUSTRATED 

In this work the anatomic changes accompanying pregnancy, labor, and the 
puerperium are described more fully and lucidly than in any other text-book on 
the subject. The exposition of these sections is based mainly upon studies of 
frozen specimens. Unusual consideration is given to embryologic and physiologic 
data of importance in their relation to obstetrics. 

Buffalo Medical Journal 

" As a practical text-book on obstetrics for both student and practitioner, there is left very- 
little to be desired, it being as near perfection as any compact work that has been published." 



Webster's 
Diseases of Women 

A Text=Book of Diseases of Women. By J. Clarence Webster, 
M. D. (Edin.), F. R. C. P. E., Professor of Gynecology and Obstetrics 
in Rush Medical College. Octavo of 712 pages, with 372 text-illustra- 
tions and 10 colored plates. Cloth, $7.00 net ; Half Morocco, $8.50 net. 

Dr. Webster has written this work especially for the general practitioner, dis- 
cussing the clinical features of the subject in their widest relations to general 
practice rather than from the standpoint of specialism. The magnificent illus- 
trations, three hundred and seventy-two in number, are nearly all original. 

Howard A. Kelly. M, D. 

Professor of Gynecologic Surgery, Johns Hopkins University. 

"It is undoubtedly one of the best works which has been put on the market within recent 
years, showing from start to finish Dr. Webster's well-known thoroughness. The illustrations 
are also of the highest order." 



SAUNDERS 1 BOOKS ON 



Hirst's 
Text-Book of Obstetrics 

The New (7th) Edition 



A Text-Book of Obstetrics. By Barton Cooke Hirst, M. D., 
Professor of Obstetrics in the University of Pennsylvania. Handsome 
octavo of 1013 pages, with 895 illustrations, 53 of them in colors. 
Cloth, $5.00 net ; Half Morocco, $6.50 net. 

INCLUDING RELATED GYNECOLOGIC OPERATIONS 

Immediately on its publication this work took its place as the leading text-book 
on the subject. Both in this country and in England it is recognized as the most 
satisfactorily written and clearly illustrated work on obstetrics in the language. 
The illustrations form one of the features of the book. They are numerous and 
the most of them are original. In this edition the book has been thoroughly revised. 
Recognizing the inseparable relation between obstetrics and certain gynecologic 
conditions, the author has included all the gynecologic operations for complica- 
tions and consequences of childbirth, together with a brief account of the diagnosis 
and treatment of all the pathologic phenomena peculiar to women. 



OPINIONS OF THE MEDICAL PRESS 



British Medical Journal 

" The popularity of American text-books in this country is one of the features of recent 
years. The popularity is probably chiefly due to the great superiority of their illustrations 
over those of the English text-books. The illustrations in Dr. Hirst's volume are far more 
numerous and far better executed, and therefore more instructive, than those commonly 
found in the works of writers on obstetrics in our own country." 

Bulletin of Johns Hopkins Hospital 

" The work is an admirable one in every sense of the word, concisely but comprehensively 
written." 

The Medical Record, New York 

" The illustrations are numerous and are works of art, many of them appearing for the first 
time. The author's style, though condensed, is singularly clear, so that it is never necessary 
to re-read a sentence in order to grasp the meaning. As a true model of what a modern text- 
book on obstetrics should be, we feel justified in affirming that Dr. Hirst's book is without a 
rival." 



DISEASES OF WOMEN. 



HirstV 
Diseases of Women 



A Text=Book of Diseases of Women. By Barton Cooke Hirst, 
M. D., Professor of Obstetrics, University of Pennsylvania ; Gynecolo- 
gist to the Howard, the Orthopedic, and the Philadelphia Hospitals. 
Octavo of 745 pages, with 701 original illustrations, many in colors. 
Cloth, $5.00 net; Half Morocco, #6.50 net. 

THE NEW (2d) EDITION 
WITH 701 ORIGINAL ILLUSTRATIONS 

The new edition of this work has just been issued after a careful revision. 
As diagnosis and treatment are of the greatest importance in considering diseases 
of women, particular attention has been devoted to these divisions. To this end, 
also, the work has been magnificently illuminated with 701 illustrations, for the 
most part original photographs and water-colors of actual clinical cases accumu- 
lated during the past fifteen years. The palliative treatment, as well as the 
radical operative, is fully described, enabling the general practitioner to treat 
many of his own patients without referring them to a specialist. An entire sec- 
tion is devoted to ^ full description of all modern gynecologic operations, illumi- 
nated and elucidated by numerous photographs. The author's extensive ex- 
perience renders this work of unusual value. 



OPINIONS OF THE MEDICAL PRESS 



Medical Record, New York 

" Its merits can be appreciated only by a careful perusal. . . . Nearly one hundred pages 
are devoted to technic, this chapter being in some respects superior to the descriptions in 
many other text- boks." 

Boston Medical and Surgical Journal 

"The author has given special attention to diagnosis and treatment throughout the book, 
and has produced a practical treatise which should be of the greatest value to the student, the 
general practitioner, and the specialist." 

Medical News, New York 

"Office treatment is given a due amount of consideration, so that the work will be as 
useful to the non-operator as to the specialist." 



IO SAUNDERS' BOOKS ON 



G CT a # THE NEW 

THE BEST /\TOeriCcHl STANDARD 

Illustrated Dictionary 

New (7th) Edition— 5000 Sold in Two Months 



The American Illustrated Medical Dictionary. A new and com- 
plete dictionary of the terms used in Medicine, Surgery, Dentistry, 
Pharmacy, Chemistry, Veterinary Science, Nursing, and kindred 
branches ; with over ioo new and elaborate tables and many handsome 
illustrations. By W. A. Newman Dorland, M.D., Editor of "The 
American Pocket Medical Dictionary." Large octavo, 1107 pages, 
bound in full flexible leather. Price, $4.50 net; with thumb index, 
$5.00 net. 

IT DEFINES ALL THE NEW WORDS— MANY NEW FEATURES 

The American Illustrated Medical Dictionary defines hundreds of the newest 
terms not denned in any other dictionary — bar none. These new terms are live, 
active words, taken right from modern medical literature. 

It gives the capitalization and pronunciation of all words. It makes a feature 
of the derivation or etymology of the words. In some dictionaries the etymology 
occupies only a secondary place, in many cases no derivation being given at all. 

In the "American Illustrated" practically every word is given its derivation. 

Every word has a separate paragraph, thus making it easy to find a word 

quickly. 

The tables of arteries, muscles, nerves, veins, etc., are of the greatest help 
in assembling anatomic facts. In them are classified for quick study all the 
necessary information about the various structures. 

Every word is given its definition — a definition that de/ines in the fewest pos- 
sible words. In some dictionaries hundreds of words are not defined at all, refer- 
ring the reader to some other source for the information he wants at once. 

Howard A. Kelly, M. D., Johns Hopkins University, Baltimore 

" The American Illustrated Dictionary is admirable. It is so well gotten up and of such 
convenient size. No errors have been found in my use of it." 

J. Collins Warren, M. D„ LL.D., F.R.C.S. (Hon.), Harvard Medical School 

" I regard it as a valuable aid to my medical literary work. It is very complete and of 
convenient size to handle comfortably. I use it in preference to any other." 



GYXECOLOGY AND OBSTETRICS u 

Penrose's 
Diseases of Women 

Sixth Revised Edition 



A Text-Book of Diseases of Women. By Charles B. Penrose, 
M. D., Ph. D., formerly Professor of Gynecology in the University of 
Pennsylvania ; Surgeon to the Gynecean Hospital, Philadelphia. Oc- 
tavo volume of 550 pages, with 225 fine original illustrations. Cloth, 

$3-7 S net - 

ILLUSTRATED 

Regularly every year a new edition of this excellent text-book is called for, 
and it appears to be in as great favor with physicians as with students. Indeed, 
this book has taken its place as the ideal work for the general practitioner. The 
author presents the best teaching of modern gynecology, untrammeled by anti- 
quated ideas and methods. In every case the most modern and progressive 
technique is adopted and made clear by excellent illustrations. 

Howard A. Kelly, M.D.. 

Professor of Gynecologic Surgery, Johns Hopkins University, Baltimore. 
" I shall value very highly the copy of Penrose's * Diseases of Women ' received. I have 
already recommended it to my class as THE best book." 



Davis' Operative Obstetrics 

Operative Obstetrics. By Edward P. Davis, M.D., Professor of 
Obstetrics at Jefferson Medical College, Philadelphia. Octavo of 483 
pages, with 264 illustrations. Cloth, $5.50 net; Half Morocco, $7.00 net. 

INCLUDING SURGERY OF NEWBORN 

Dr. Davis' new work is a most practical one, and no expense has been spared 
to make it the handsomest work on the subject as well. Every step in every 
operation is described minutely, and the technic shown by beautiful new illustra- 
tions. Dr. Davis' name is sufficient guarantee for something above the mediocre. 



'* SAUNDERS' BOOKS ON 



Dorland's 
Modern Obstetrics 



Modern Obstetrics: General and Operative. By W. A. Newman 
Dorland, A. M., M. D., Professor of Obstetrics at Loyola University, 
Chicago, Illinois. Handsome octavo volume of 797 pages, with 201 
illustrations. Cloth, $4.00 net. 

Second Edition, Revised and Greatly Enlarged 

In this edition the book has been entirely rewritten and very greatly enlarged. 
Among the new subjects introduced are the surgical treatment of puerperal sepsis, 
infant mortality, placental transmission of diseases, serum-therapy of puerperal 
sepsis, etc. By new illustrations the text has been elucidated, and the subject pre- 
sented in a most instructive and acceptable form. 

Journal of the American Medical Association 

" This work deserves commendation, and that it has received what it deserves at the hands 
of the profession is attested by the fact that a second edition is called for within such a short 
time. Especially deserving of praise is the chapter on puerperal sepsis." 

Davis* Obstetric and 
Gynecologic Nursing 

Obstetric and Gynecologic Nursing. By Edward P. Davis, A. M., 
M. D., Professor of Obstetrics in the Jefferson Medical College and 
Philadelphia Polyclinic ; Obstetrician and Gynecologist, Philadelphia 
Hospital. i2mo of 480 pages, illustrated. Buckram, #1.75 net. 

NEW (4th) EDITION 
Obstetric nursing demands some knowledge of natural pregnancy, and gyne- 
cologic nursing, really a branch of surgical nursing, requires special instruction 
and training. This volume presents this information in the most convenient 
form. This third edition has been very carefully revised throughout, bringing the 
subject down to date. 

The Lancet, London 

" Not only nurses, but even newly qualified medical men, would learn a great deal by a 
perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- 
mend." 



GYNECOLOGY AND OBSTETRICS. *3 

Kelly and Cullen's 
Myomata of the Uterus 



Myomata of the Uterus. By Howard A. Kelly, M. D., Professor 
of Gynecologic Surgery at Johns Hopkins University; and Thomas S. 
Cullen, M. B., Associate in Gynecology at Johns Hopkins University. 
Large octavo of about 700 pages, with 388 original illustrations, by 
August Horn and Hermann Becker. Cloth, $7.50 net ; Half Morocco, 
$9.00 net. 

ILLUSTRATED BY AUGUST HORN AND HERMANN BECKER 

This monumental work, the fruit of over ten years of untiring labors, will 
remain for many years the last word upon the subject. Written by those men 
who have brought, step by step, the operative treatment of uterine myoma to 
such perfection that the mortality is now less than one per cent., it stands out as 
the record of greatest achievement of recent times. 

Surgery, Gynecology, and Obstetrics 

" It must be considered as the most comprehensive work of the kind yet published. It 
will always be a mine of wealth to future students." 



Cullen's Adenomyoma of the Uterus 

Adenomyoma of the Uterus. By Thomas S. Cullen, M. B. Octavo of 275 
pages, with original illustrations by Hermann Becker and August Horn. Cloth, 
#5.00 net; Half Morocco, $6.50 net. 

"A good example of how such a monograph should be written. It is an excellent 
work, worthy of the high reputation of the author and of the school from which it 
emanates.' ' — The Lancet, London. 

Cullen's Cancer of the Uterus 

Cancer of the Uterus. By Thomas S. Cullen, M. B. Large octavo of 693 
pages, with over 300 colored and half-tone text-cuts and eleven lithographs. Cloth, 
#7.50 net ; Half Morocco, $8.50 net. 

" Dr. Cullen' s book is the standard work on the greatest problem which faces the 
surgical world to-day. Any one who desires to attack this great problem must have 
this book." — Howard A. Kelly. M. D., Johns Hopkins University. 



14 SAUNDERS' BOOKS ON 



Schaffer and Edgar's Labor and Operative Obstetrics 

Atlas and Epitome of Labor and Operative Obstetrics. By Dr. 

0. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, 
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University 
Medical School, New York. With 14 lithographic plates in colors, 139 text- 
cuts, and in pages of text. Cloth, $2.00 net. In Saunders* Hand-Atlases. 



Schaffer and Edgar's Obstetric Diagnosis and 
Treatment 

Atlas and Epitome of Obstetric Diagnosis and Treatment. By Dr. 

O. Schaffer, of Heidelberg. Edited, with additions, by J. Clifton Edgar, 
M. D., Professor of Obstetrics and Clinical Midwifery, Cornell University 
Medical School, New York. With 122 colored figures on 56 plates, 38 text- 
cuts, and 315 pages of text. Cloth, $3.00 net. Saunders' Hand-Atlases. 



Schaffer and Norris* Gynecology 

Atlas and Epitome of Gynecology. By Dr. O. Schaffer, of Heidel- 
berg. Edited, with additions, by Richard C. Norris, A. M., M. D., 
Gynecologist to Methodist Episcopal and Philadelphia Hospitals. With 207 
colored figures on 90 plates, 65 text-cuts, and 308 pages of text. Cloth, 
$3. 50 net. In Saunders' Hand-Atlas Series. 



Galbraith's Four Epochs of Woman's Life 

New (2d) Edition 

The Four Epochs of Woman's Life : A Study in Hygiene. By Anna 
M. Galbraith, M. D., Fellow of the New York Academy of Medicine, etc. 
With an Introductory Note by John H. Musser, M. D., University of 
Pennsylvania. i2mo of 247 pages. Cloth, $1.50 net. 

Birmingham Medical Review, England 

"We do not, as a rule, care for medical books written for the instruction of the public. 
But we must admit that the advice in Dr. Galbraith's work is, in the main, wise and 
wholesome." 



Garrigues' Diseases of Women Third Edition 

A Text=Book of Diseases of Women. By Henry J. Garrigues, M. D., 
Gynecologist to St. Mark's Hospital, New York City. Octavo of 756 pages, 
illustrated. Cloth, $4. 50 net ; Half Morocco, $6.00 net. 



GYNECOLOGY AND OBSTETRICS. 15 

Schaffer and Webster's 
Operative Gynecology 



Atlas and Epitome of Operative Gynecology. By Dr. O. Schaf- 
fer, of Heidelberg. Edited, with additions, by J. Clarence Webster, 
M.D. (Edin.), F.R.C.P.E., Professor of Obstetrics and Gynecology in 
Rush Medical College, in affiliation with the University of Chicago. 
42 colored lithographic plates, many text-cuts, a number in colors, and 
138 pages of text. In Saunders* Hand- Atlas Series. Cloth, $3.00 net. 



Much patient endeavor has been expended by the author, the artist, and the 
lithographer in the preparation of the plates of this atlas. They are based on 
hundreds of photographs taken from nature, and illustrate most faithfully the 
various surgical situations. Dr. Schaffer has made a specialty of demonstrating 
by illustrations. 

Medical Record, New York 

" The volume should prove most helpful to students and others in grasping details usually 
to be acquired only in the amphitheater itself." 

De Lee's 

Obstetrics for Nurses 



Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor of 
Obstetrics in the Northwestern- University Medical School ; Lecturer 
in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook 
County, and Chicago Lying-in Hospitals. i2mo volume of 508 pages, 
fully illustrated. Cloth, $2.50 net. 

THE NEW (4th) EDITION 

While Dr. De Lee has written his work especially for nurses, yet the prac- 
titioner will find it useful and instructive, since the duties of a nurse often devolve 
upon him in the early years of his practice. The illustrations are nearly all 
original, and represent photographs taken from actual scenes. The text is the 
result of the author's many years' experience in lecturing to the nurses of five 
different training schools. 

J. Clifton Edgar, M. D., 

Professor of Obstetrics and Clinical Midwifery, Cornell University , New York. 
" It is far and away the best that has come to my notice, and I shall take great pleasure in 
recommending it to my nurses, and students as well." 



16 SAUNDERS' BOOKS ON GYNECOLOGY AND OBSTETRICS. 

American Pocket Dictionary New (8th) Edition 

The American Pocket Medical Dictionary. Edited by W, 
A. Newman Dorland, A. M., M. D. 677 pages. #1.00 net; with 
patent thumb index, #1.25 net. 

James W. Holland, M. D., 

Professor of Medical Chemistry and Toxicology at tke Jefferson Medical College^ 
Philadelphia. 

" I am struck at once with admiration at the compact size and attractive exterior. I 
can recommend it to our students without reserve." 

Cragin's Gynecology. New (7th) Edition 

Essentials of Gynecology. By Edwin B. Cragin, M. D., 
Professor of Obstetrics, College of Physicians and Surgeons, New 
York. Crown octavo, 232 pages, 59 illustrations. Cloth, $1.00 
net. In Saunders 1 Question- Compend Series. 

The Medical Record, New York 

" A handy volume and a distinct improvement of students' compends in general. 
No author who was not himself a practical gynecologist could have consulted the 
student's needs so thoroughly as Dr. Cragin has done." 

AshtOn'S Obstetrics. New (7th) Edition 

Essentials of Obstetrics. By W. Easterly Ashton, M. D., 
Professor of Gynecology in the Medico-Chirurgical College, Phila- 
delphia. Revised by John A. McGlinn, M. D., Assistant Professor 
of Obstetrics in the Medico-Chirurgical College of Philadelphia. 
i2mo of 287 pages, 109 illustrations. Cloth, $1.00 net. In Saunders* 
Question- Compend Series, 

Southern Practitioner 

"An excellent little volume ccntaining correct and practical knowledge. An admir- 
able compend, and the best condensation we have seen." 

Barton and Wells* Medical Thesaurus 

A Thesaurus of Medical Words and Phrases. By Wilfred 
M. Barton, M. D., Assistant to Professor of Materia Medica and 
Therapeutics, Georgetown University, Washington, D. C. ; and 
Walter A. Wells, M. D., Demonstrator of Laryngology , George- 
town University, Washington, D. C. i2mo of 534 pages. Flex- 
ible leather, $2.50 net; with thumb index, $3.00 net. 

Macfarlane's Gynecology for Nurses second Edition 

A Reference Hand-Book of Gynecology for Nurses. By Cath- 
arine Macfarlane, M. D., Gynecologist to the Woman's Hospital of 
Philadelphia. 32010 of 150 pages, with 70 illustrations. Flexible 
leather, $1.25 net. 

A. M. Seabrook, M. D„ 

Woman's Medical College of Philadelphia. 

" It is a most admirable little book, covering in a concise but attractive way the subject 
from the nurse's standpoint." 



